Police Applicant Screening Service

Allstate Center, Suite 135
3200-34th Street South
St. Petersburg, FL 33711-3829

PERSONAL HISTORY FORM
Download Personal History Form
(Requires Adobe Acrobate Reader- click icon  for Free copy)

Instructions

  1. The Personal History Form (PHF) must be completed by the applicant.
  2. Use this form. (Make a copy if you want to create a draft first.) Hand print answers in ink using
    UPPERCASE LETTERS, or type using a standard font (similar to these instructions).
  3. Read all questions carefully before you start filling in the form.
  4. Answer all questions fully and accurately. All information is subject to verification by PASS
    Investigators and Polygraph Examination.
  5. Leave no spaces blank. If a question does not apply, mark "N/A" in the space.
  6. Provide all information. If any answer needs more space, use the back of the sheet.
  7. Complete mailing addresses for residences, employers and references are mandatory and must
    include house number, box number or apartment number (if applicable), street name, city, state and
    zip code (or foreign country and mailing code).
  8. Many questions ask for the "county" (the political sub-division of a state) in which you lived or an
    event occurred. Do not mistake this for "country" (i.e. a nation).
  9. Telephone numbers must include area code.
  10. These forms must be sworn and notarized before a representative of PASS.
  11. Do not sign or date the signature pages until told to do so at the PASS office.

WARNING

Any misrepresentation, falsification, omission or concealment of a material fact will subject the
applicant to disqualification and may subject the applicant to discharge if discovered subsequent
to employment.

  1. Are you willing to submit to an Administrative Interview and/or a polygraph examination to verify all
    information supplied in this Personal History Form? Yes- or No-. If no, attach a letter stating the reason(s).

  2. Full Name: ____________________________________________________________________
     First - Middle - Last

  3. Date Of Birth: __________________ Social Security Number: _______-_____-________
    Month - Day - Year

  4. Home Phone : ________________________ Work Phone: __________________________
    (Area Code) Number (Area Code) Number

  5. Present: Height: _______ Weight: _______ Eye Color: ______ Hair Color: ________

  6. Place Of Birth: ____________________________________________________________
    City - County - State - Country

  7. I am a Citizen of the United States: Yes- or No-

  8. Naturalized Certificate No. _________________ Country of Origin ___________________

  9. List all other names used (adoption, legal change, alias, maiden, nickname, pen-name, etc.):

__________________________________________ __________________________________________

__________________________________________ __________________________________________

10.    List each and every place you have resided since your first year of high school, including all college, military
         or other temporary addresses. Begin with your present address and work back.

From

To

Full Address

 

Present

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

Continue Residences On Next Page

 

Residences Continued (If more space is needed, write on the back of the page using the same format.)

From

To

Full Address

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

   

House Number: Apt or Lot Number:

Street Name: City:

State & ZIP: COUNTY:

10. HISTORY OF FAMILY OR ASSOCIATION. Are you, currently or formerly, related to or associated
with any individual who has a criminal history?

         ____Yes      ____No

If yes, provide the following information.

Relationship

Name

Date of Birth or Social Security Number

     
     
     
     
     

 

 

11. EMPLOYMENT: List each and every place you have been employed since you began working, including full
and part time jobs, internships, and military service. Start with your present job and work back. Omit none. For
some applicants this is not difficult. For those with long employment histories, more effort is required, such as taking
time to draft a list from memory, ask help from family members, obtain copies of previous applications on which you
have listed prior appointments, etc. Some applicants may be tempted to skip employment for which they have
difficulty in recalling dates and addresses. This is a big mistake. The PASS background investigation includes review
of Social Security records - which are very complete. Law enforcement employers are particularly interested in hiring
people who are capable of making honest, accurate and complete disclosures - and avoiding those who are not capable
of doing so. Omissions are grounds for disqualification. You must provide the full, accurate, current address for each
employer, and show any dates of unemployment or military service within the sequence. Please do not use vague terms
such as "Personal Reasons" when giving your reasons for leaving a job. Use more specific terms such as "Fired, Asked
To Resign, Voluntarily Resigned, Laid Off, Better Pay, etc."

Employment # 1

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 2

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 3

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 4

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 5

From:

To:

-Full -Part Time

Name of Supervisor:

 

(Continue employments on next page.)

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 6

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 7

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 8

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 9

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 10

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

Employment # 11

From:

To:

-Full -Part Time

Name of Supervisor:

Name:

House Number:

Street:

City:

State & Zip:

COUNTY:

Position Title or Duties:

 

Reason For Leaving:

 

-Check here if you or a relative owned or operated this business.

If more space is needed to list all employment check here , and write on the back of this page using the
same format.

12. MILITARY SERVICE: Have you ever served in the Armed Forces of the United States or a foreign
military service?

  • No. (You must complete the "DISCLAIMER OF MILITARY SERVICE" form and attach it to this document.)
  • Yes. (You must complete the "REQUEST PERTAINING TO MILITARY RECORDS" form and attach
    it to this document AND provide the following information.

Dates

Service Number

Branch

Last Rank

Type of Discharge

From:

To:

        

From:

To:

        

From:

To:

        

From:

To:

        

 

 

MITARY DISCIPLINE: If you did serve in the military, were you ever court-martialed, tried on charges, given
a Captain’s Mast, punished under Article 15, or the subject of a summary court or other military discipline?

__ Yes __No

If yes, provide the following information:

Date

Charge/Violation

Disposition

 

   

 

 

   

 

 

   

 

 

   

 

13. DISCHARGED BY AN EMPLOYER: Have you ever been discharged or asked to resign from
employment or the military ? -Yes -No

If yes, give the following details concerning all such occurrences:

Employer

Date

Supervisor

Reason

 

     

 

 

     

 

 

     

 

14. DISCIPLINARY ACTIONS BY AN EMPLOYER Were you ever the subject of any disciplinary
action or inquiry of any kind by an employer (includes counseling, warning, reprimand, suspension, or loss
of pay) or the subject of an Internal Affairs investigation for violation of a rule, criminal violation, citizen
complaint or civil complaint? -Yes -No

If yes, provide the following details concerning all such occurrences:

Date

Employer

Violation

Results

 

     

 

 

     

 

 

     

 

15. ARRESTS OR SUMMONS. Have you ever been arrested, issued a summons or Notice To
Appear (other than traffic), taken into custody, questioned or investigated concerning any criminal
violation (felony or misdemeanor) or violation of the Uniform Code of Military Justice?

         _____Yes ____No

NOTE: Florida law requires law enforcement applicants to list any expungement or
sealing of record, whether adult or juvenile, civilian or military.

If yes, provide the following information.

Date

City & State

Police Agency

Violation / Actual Charge

Court Disposition / Sentence

 

       

 

 

       

 

 

       

 

If more space is needed to list all charges check here , and write on the back of this page using the same format.

16. DRIVER’S LICENSES. List ALL driver’s licenses you have held in any state. Start with current license and work back.

State

Type

License Number

(Required for any still valid)

Date Issued

Still Valid?

(Yes or No)

Date Expired or Surrendered

           
           
           

 

17. Has your driver’s license ever been suspended or revoked in any state? Yes- No-

If yes, provide the following information.

Date

State

S = Suspended

R = Revoked

Give Reason

Date Restored

         
         
         

18. List ALL moving traffic violations in any state at any age, including any investigated by police.
Include any violations where disposition was attendance of a driving school to avoid points. Use the back
of the sheet if more space is needed. Failure to list ALL may be grounds for disqualification.

Date

Violation/Actual Charge

Location: City and State

Disposition or Sentence

Police Agency

 

       

 

 

       

 

 

       

 

 

       

 

 

       

 

 

       

 

19. Have you EVER tried, used or experimented with Marijuana, Hashish or THC?

Yes- No-

If yes, provide the following information:

Substance

Month & Year First Tried

Month & Year Last Tried

Total Number of Times Tried

Marijuana / THC

     

Hashish

     

20. Have you EVER illegally tried, used, possessed, sold, delivered or transported or experimented
with ANY of the following drugs? If yes to any of the following provide details on an attached sheet.

Drug

Some Common Names

No

Yes

Amphetamines

or Methamphetamines

Benzedrine, Dexedrine, Bennies, Speed, Uppers, White Crosses, Crank, Crystal, Ice, etc.

   

Barbiturates

Phenobarbital, Secobarbital, Nembutal, Seconal, Amytal, etc.

   

Cocaine, Crack or any Cocaine Derivative

Coke, Crack, Corrine, Gold Dust, Flake, Snow, Powder, Blow, Nose Candy, etc.

   

DMT

Dimethlytriptamine, AMT, Businessman’s High, etc.

   

Heroin or Methadone

Smack, Horse, Black Tar, China White, etc.

   

Inhalants

Huffing, Wheezing, Nitrous Oxide, Solvents, Glue, Fumes, etc.

   

LSD

D-Lysergic Acid Diethylamide, Acid, Sugar, Sunshine, Dots, etc.

   

MDMA

Ecstasy, XTC, X, etc.

   

Mescaline

Mesc, Chocolate Mesc

   

Methaqualone

Quaaludes, Ludes, Downers, etc.

   

Opium or Derivatives

Codeine, Morphine, etc.

   

Painkillers

Diluadid, Percodan, Percoset, Hydrocodone, Hydromorphone, Meperidine, Oxycodone, Oxy Contin, etc.

   

PCP

Phencyclidine, Angel Dust, Hog, Peace Pill, Tea, Crystal Tea, etc.

   

Psilocybin

Mushrooms, Shrooms, etc.

   

Rohypnol

Flunitrazepam, Roofies, Date Rape, etc.

   

Steroids

Roids, Bahama Blues, Juice, etc.

   

Tranquilizers

Diazepam, Valium, etc.

   

Have you ever obtained a prescription drug through fraud?

   

21. Have you ever applied for any law enforcement position or taken a civil service examination for
another government position? -Yes -No

If yes, provide details:

Date

Place

Position

Results

       
       
       

22. HIGH SCHOOL EDUCATION. Indicate whether you:

-Graduated from High School or -Obtained a G.E.D. Provide:

Date

Name & Address of Institution which provided diploma or G.E.D.

 

Name:

Number & Street:

City:

State & Zip:

COUNTY:

23. Do you speak any language in addition to English? Yes- or No-

If yes, other language(s) spoken: ______________________________________________

24. COLLEGE EDUCATION: List all colleges or universities you have attended.

Dates

Institution

Graduate?

Results

From:

 

To:

Name:

Number & Street:

City:

State & ZIP:

COUNTY:

-Yes

-No

Credit Hours:

Degree:

From:

 

To:

Name:

Number & Street:

City:

State & ZIP:

COUNTY:

-Yes

-No

Credit Hours:

Degree:

25. TRAINING: List any professional licenses or public safety certification such as law enforcement officer,
corrections officer, emergency medical technician, etc.

Date

Institution or Granting Authority

Type of License or Certification

 

 

Name:

Number & Street:

City:

State & ZIP:

 

 

 

 

 

 

Name:

Number & Street:

City:

State & ZIP:

 

 

 

 

 

 

Name:

Number & Street:

City:

State & ZIP:

 

 

 

 

26. CONTRACTUAL OBLIGATIONS: Are you currently under any contractual obligation to an employer
(such as an employment contract or reimbursement of training costs? -Yes -No

If yes, what is the name of the employer __________________________________

When does it expire? ________________________.

27. DISCIPLINE DURING TRAINING OR EDUCATION: Were you ever suspended, expelled or placed on probation while in a high school, vocational school, law enforcement training facility, university or college? -Yes -No

If yes, provide the following information:

Date

Charge/Violation

Disposition

 

   

 

 

   

28. FINANCIAL STATUS. Please list ALL debts that you currently owe (credit cards, charge accounts, mortgages, installment loans, etc.) including those that are currently in good standing and those in which you are behind
or are involved in any collection proceedings:

Name of creditor or Company

Present Balance

Monthly Payment

Number of payments behind

       
       
       
       
       
       
       
       

Financial Status Continued: Please answer the following questions. If you answer yes to any question, please
provide details (when, where and what) on the back of this sheet.

Question

No

Yes

Have you ever been refused a bond?

   

Have you ever been refused credit because of bad credit history?

   

Will your financial situation require income other than that provided by your salary?

   

Do you have any monetary judgments, liens or attachments against you?

   

Have you ever been subject to a civil or small claims court action?

   

Are you presently subject to any pending civil or small claims court action?

   

29. SUBVERSIVE ORGANIZATIONS: Are you now, or have you ever been, a member of any foreign
or domestic organization , association, group, militia, movement, party or other combination of persons which
has adopted, advocated or approved the use of force or violence to oppose the government or deny other
persons their rights under the Constitution of the United States, or which seeks to alter the form of the United
States government by unconstitutional means? -Yes -No

If yes, explain fully on the back of this sheet.

30. MISCELLANEOUS: Do you have any knowledge or information, in addition to that specifically called for
in the preceding questions, which is or which may be relevant, directly or indirectly, to the investigation of your
eligibility or fitness for a law enforcement position, including, but not limited to, knowledge or information concerning
your character, habits, employment , education, subversive activities, family, associations, criminal record,
traffic violations, ownership or use of weapons, residence or otherwise? -Yes -No

If yes, explain fully on the back of this sheet.

30. PERSONAL REFERENCES

  • List five personal references who have known you for at least one year.
  • Do not use relatives.
  • Use only one member in a household or family.
  • Provide full accurate addresses and telephone numbers.

Name & Address

(A/C) Telephone No.

Name:

Address:

City:

State & Zip:

( )

Known Since:

Name:

Address:

City:

State & Zip:

( )

Known Since:

Name:

Address:

City:

State & Zip:

( )

 

Known Since:

Name:

Address:

City:

State & Zip:

( )

 

Known Since:

Name:

Address:

City:

State & Zip:

( )

 

Known Since:

Reminder: You must bring the following documents to your Administrative Interview. Bring the original or
certified copy (notarized or stamped by issuing authority). The documents will be examined and returned to
you before you leave.

  • Birth Certificate
  • Naturalization Papers
  • Social Security card
  • Driver’s License
  • High School Diploma or G.E.D.
  • College Diploma(s) and Transcripts

 

  • Military Record - DD 214 (Long Form) and Discharge Certificate
  • Police or Corrections Officer Certifications (if applicable)
  • Divorce Decree(s) or Legal Change of Name Order(s)

 

 

 

APPLICANT SIGNATURE and ACKNOWLEDGEMENTS

I hereby swear or affirm that this Personal History Form contains no misrepresentations, falsifications, omissions or concealment of material fact, and that all information and statements contained herein are true and complete to the best of my knowledge and belief. I am aware that all information and statements contained herein are subject to investigation; and, should investigation disclose any misrepresentation, falsification, omission or concealment of material fact, my application may be rejected, my name removed from eligibility for law enforcement employment in Pinellas County, Florida, and I may be subject to discharge from any employment based all or in part on such information and statements.

I also acknowledge that records established and maintained pursuant to public expenditures may be classified as public records and may be released to parties requesting them. As an applicant for a law enforcement position in Pinellas County, Florida, and in consideration of the Pinellas Police Standards Council and the Police Applicant Screening Service (also known as PASS) and their members processing and considering my application for eligibility, certification and employment, I hereby expressly release the Pinellas Police Standards Council and PASS, along with their members and employees, from any liability or damages which may result from the release of any record pertaining to my application.

I understand that PASS is not an employer and that participation in this process does not guarantee a job interview or job offer.

 

_________________________________

(Signature of Applicant)

State of Florida

County of Pinellas

Sworn to and subscribed before me this ______ day of ___________, 200_ by

___________________________, who is personally known to me or has produced the following

(Printed Name)

identification ______________________________________.

 

__________________________________

(Signature of Notary )

NOTARY PUBLIC, State of Florida At Large

___________________________________ My Commission Number _________________
Printed Name
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(Requires Adobe Acrobate Reader- click icon  for Free copy)

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