Transcription
Central Texas College Police AcademyPERSONAL HISTORY STATEMENTAttachmentsTo all Police Academy Applicants:The following is a list of items that you must include in your Personnel HistoryStatement packet when you turn it in. Make copies of all documents, except asnoted. If you have to send off for one of the following, make a copy of the letterrequesting the document and attach it to your packet. This will suffice until youhave the document in hand. Completed Personal History Statement, in black ink and in your handwriting.TYPED PHS WILL NOT BE ACCEPTED! FAST Fingerprint confirmation 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. Copy of your High School diploma or GED certificate. Sealed original certified copy of your college transcript. (No photo copy) Photocopy of your college diploma. Copy of your DD-214 if applicable. Must possess an honorable discharge. Original certified copy of your Naturalization papers, if applicable. (No photo copy),we will verify the original, however you will have to bring it in when you drop offyour packet. Copy of current proof of automobile liability insurance. Written disposition of any arrests from the arresting agency* If you have been convicted of any type of family violence, you will automaticallybe disqualified from consideration for the position of a Police Academy Cadet.All of the above documents are due NLT: June 19, 2020 by 12:00PMyou must make an appointment when turning in your paperwork.
BACKGROUND/PT Test:Once your packet has been accepted we will review it for completeness. You willthen have a Physical Fitness test scheduled where you will be required to row 2000meters (on a Concept II rower) for time based on your weight, sex and age. Youmust attain 25% of your VO2 max in order to be accepted into the police academy.Once your paperwork has been cleared to continue in the process you will thenreceive the following forms, Signed L-2 (Licensee Medical Condition form); signed by a licensed physician inthe State of Texas. Signed L-3 (Licensee Psychological Condition form); signed by a licensedpsychologist or a psychiatrist who is licensed in the State of Texas.These forms will be required to be completed and returned to the academy staffNLT: June 26, 2020 by12:00PM If anything else is needed you will be advised to produce them by yourbackground investigator. Once everything has been submitted you will be given the paperwork which willallow you to register for the course. DO NOT:o Try to get ahead and get your Psychological or Physical Exam completedprior to receiving the paperwork from the academy.o Falsify anything! If you are found to be untruthful or withhold anyinformation you will be removed from the academy process. Once you have everything it must be turned in to the Protective ServicesDepartment (Police Academy) located at building #122 room #101.
Central Texas College Police AcademyPERSONAL HISTORY STATEMENTCosts Associated with Academy Attendance: List classes which the student will receive credit hours from passing the academyare: CJLE 1506 5 semester hours CJLE 1512 5 semester hours CJLE 1518 5 semester hours CJLE 1524 5 semester hours CJLE 1529 3 semester hours TOTAL 23 semester hours Tuition is based on the current CTC rate per credit hour for each of the abovelisted courses. Go to the link below for current and future rates: : paying-forcollege/tuition-and-fees-summary/ This does not cover the cost of books, uniforms, equipment, ammunition . Books: Avg cost for Texas Criminal and Traffic Law Manual 2015-2016 about 46 The Texas Criminal and Traffic Law Manual, made by LexisNexus Cost of handout materials from CTC Bookstore about 92 Equipment: Pistol belt Holster for pistol (Glock 22 if not supplying their own pistol) Double Magazine pouch for pistol 1 set of Handcuffs with case and key Flashlight with holster ASP Baton with Scabbard Mouth guard for physical training
Ammunition: If you are going to use a CTC Academy handgun you will needto purchase 40 caliber ammunition. Each student will requirethe following:1. 1000 rounds (ball ammo) for 40 cal pistol2. 25 rounds of rifled slug for 12 gauge shotgun (shotgunwill be provided)3. 25 rounds of double 00 buck shot for 12 gauge shotgun(shotgun will be provided) Uniforms: Daily uniform is: Black 5.11 style short sleeve shirt (moisture wicking) forday academy Charcoal Grey 5.11 style short sleeve for nightacademy Khaki 5.11 style tactical pants or Propper Khaki pants(go to www.lapolicegear.com for good prices. Black polishable toed boots Black beltPT Uniform: Navy blue shorts or sweat pants Heather Gray PT T-shirt Navy blue sweat shirt
Central Texas College Police AcademyPOLICE ACADEMY CADET PERSONAL HISTORY STATEMENTNAMEDATE ISSUEDCOMPLETE AND RETURN BY March 27, 2020 NLT 12 NoonYou must make an appointment in order to turn your paperwork in!!! Please emailPolice.Academy@ctcd.edu or call 254-616-3316 to make your appointmentI am applying for:[ XX] Peace Officer Academy Cadet PID#[] County Jailer Academy Cadet PID#[] Telecommunicator Academy Cadet PID#
Personal History StatementNAME:Personal History Statement InstructionsCadets are exposed to confidential and law enforcement sensitive information. A thorough background investigation is required toproperly evaluate the suitability of applicants for placement in the Basic Peace Officer Academy. Although it is an achievement toreach the background phase of the application process, this is still a competitive process and does not, in any way, guaranty selection inthe Basic Peace Officer Academy.These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is essential thatthe information is accurate in all respects so please read all instructions carefully before proceeding. The Personal HistoryStatement will be used as a basis for a background investigation that will determine your eligibility for becoming a Cadet in theAcademy.1.Your application must be printed legibly in BLACK INK by the applicant it CANNOT BE TYPED, it must be in yourhandwriting. 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 accurateand 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 makingthat entry on this history statement. Errors will not be viewed favorably. ALL ADDRESSES MUST BE COMPLETEWITH ZIP CODES.5.If you need additional space for your answers, attach an additional sheet or sheets as needed. Be sure to indicate what questionnumber and page this refers to.6.An accurate and complete form will help expedite your investigation. Omissions or falsifications will result indisqualification.7.You are responsible for furnishing any changes and/or updating your application as needed, such as address changes ortelephone changes in writing.8.Any candidate submitting an incomplete application WILL NOT BE CONSIDERED FOR THE ACADEMY. Yourapplication will be evaluated on completeness and neatness.9.All documents requested must be submitted with the application (photocopies are acceptable in most cases). Requireddocuments vary according to the position being sought and the history of the applicant. Hiring agency please check offdocuments required- modify list as necessary Completed Personal History Statement FAST Fingerprint check return. 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. Copy of your High School diploma or GED certificate. Sealed original certified copy of your college transcript. (No photo copy) Photocopy of your college diploma. 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. Signed L-2 (Licensee Medical Condition form); signed by a licensed physician, NOT TO BE COMPLETED UNTILit is given to you after the due date of your PHS. Signed L-3 (Licensee Psychological Condition form); signed by a licensed psychologist or a psychiatrist, NOT TOBE COMPLETED UNTIL it is given to you after the due date of your PHS.10. If you have any questions, please contact your assigned background investigator11. When submitting the completed documents, please place them in a sealed envelope marked Personal and Confidential to yourassigned background investigator.CTCPA PHS 1-10-19Page 2 of 35Initial this page to indicate that you have provided complete and accurate information:
Personal History StatementNAME:Applicant Qualification SectionBefore 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.Initials: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 afelony.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 thisstate, other state, or while serving in the military.I have never had a military court martial that resulted in a dishonorable or bad conductdischarge.DISQUALIFICATIONThere are very few automatic basis for rejection. Even issues of prior misconduct, employee terminations, andarrests are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements oromissions can and often will result in your application being rejected, regardless of the nature or reason for themisstatements/omissions. In fact, the number one reason individuals “fail” background investigations isbecause they deliberately withhold or misrepresent job-relevant information from their prospective employer.This personal history statement is a governmental document. Be truthful, as there are criminal consequencesfor lying on a governmental document.Once you begin: Print neatly, in black ink, responses to all items and questions. If a question does not apply to you, write“N/A” (not applicable) in the space provided for your response. If you cannot obtain or remember certaininformation, indicate so in your response. If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate whatquestion number and page this refers to. Be as complete, honest and specific as possible in your responses.CTCPA PHS 1-10-19Page 3 of 35Initial this page to indicate that you have provided complete and accurate information:
SECTION 1: PERSONAL1. Last NameFirstMISuffix2. Other Names, including nicknames, you have used or been known by.3. Street Address, (Apt, Unit)CityStateZip4. Address if different from above.5. Phone #. HomeCell6. Email: HomeWorkExt.FaxBusinessOther7. Birth Place (City / County / State / Country10. Driver License #State:Other8. DOB11. Physical descriptionHT.WT.9. Social Security #Hair ColorEye ColorExp:12. Have you ever attended a basic licensing course?If yes, provide the PID you were assigned:A. Academy NameFromYesNoToDid you Graduate?YesLocation (City / State)B. Academy NameLocation (City / State)CTCPA PHS 1-10-19Page 4 of 35Name of Training CoordinatorFromToName of Training CoordinatorNoContact NumberDid you Graduate?YesNoContact NumberInitial this page to indicate that you have provided complete and accurate information:
13. Have you ever applied to any other law enforcement agency in the last ten years (city, county, state or federal)?YesNo If yes, list ALL agencies you have applied to, starting with the most recent (give complete and accurateaddresses). All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for eachagency. If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate whatquestion number and page this refers to.A. Name of AgencyPosition Applied ForDate AppliedAddress StreetCityBackground Investigators Name (if know)StateContact Number ExtZipEmailCheck each step in the process that you completed, and your status:Steps:ApplicationWrittenConditional job offerStatus:HiredPhysical agilityOralPolygraph/CVSAPsychological Examination DateOn ListWithdrawnBackgroundMedical Date:DisqualifiedB. Name of AgencyPosition Applied ForAddress StreetCityBackground Investigators Name (if knownChief’s oralDate AppliedStateContact Number ExtZipEmailCheck each step in the process that you completed, and your status:Steps:ApplicationWrittenConditional job offerStatus:HiredPhysical agilityOralPolygraph/CVSAPsychological Examination DateOn ListWithdrawnBackgroundMedical Date:DisqualifiedC. Name of AgencyPosition Applied ForAddress StreetCityBackground Investigators Name (if known)Chief’s oralDate AppliedStateContact Number ExtZipEmailCheck each step in the process that you completed, and your status:Steps:ApplicationWrittenConditional job offerStatus:HiredCTCPA PHS 1-10-19Page 5 of 35On ListPhysical agilityOralPsychological Examination DateWithdrawnPolygraph/CVSABackgroundChief’s oralMedical Date:DisqualifiedInitial this page to indicate that you have provided complete and accurate information:
SECTION 2: RELATIVES AND REFERENCES14. IMMEDIATE FAMILY Provide all applicable information in the spaces below. Mark “N/A” if a category is not applicable or if the individual is deceased. If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate whatquestion number and page this refers to.A. Father NameDOBNAHome AddressCityStateZipWork AddressCityStateZipHome PhoneCellWork PhoneB. Step-Father NameEmailDOBNAHome Addres sCityStateZipWork AddressCityStateZipHome PhoneCellWork PhoneC. Mother NameEmailDOBNAHome AddressCityStateZipWork AddressCityStateZipHome PhoneCellWork PhoneD. Step-Mother NameEmailDOBNAHome Addres sCityStateZipWork AddressCityStateZipHome PhoneCTCPA PHS 1-10-19Page 6 of 35CellWork PhoneEmailInitial this page to indicate that you have provided complete and accurate information:
E. Spouse / Registered Domestic PartnerDOBNAHome AddressCityStateZipWork AddressCityStateZipHome PhoneYears of Marria geCellWork PhoneEmailIs there, or has there been a restraining or stay-away order in effect for this individual?YesNoF. Father-in-Law NameDOBNAHome Addres sCityStateZipWork AddressCityStateZipHome PhoneCellWork PhoneG. Mother-in-Law NameEmailDOBNAHome Addres sCityStateZipWork AddressCityStateZipHome PhoneNACellH. Former Spouse(s)CohabitantWork PhoneEmailDOB1. NameMaleFemaleHome AddressCityStateZipWork AddressCityStateZipHome PhoneYear of DissolutionCTCPA PHS 1-10-19Page 7 of 35CellWork PhoneEmailIs there, or has there been a restraining or stay-away order in effect for this individual?YesNoInitial this page to indicate that you have provided complete and accurate information:
NAI. Former Spouse(s)Cohabitant2. NameDOBMaleFemaleHome AddressCityStateZipWork AddressCityStateZipHome PhoneYear of DissolutionNACellWork PhoneEmailIs there, or has there been a restraining or stay-away order in effect for this individual?YesNoJ. Brothers and Sisters: List all living siblings, including half-siblings, foster siblings, etc.1. NameDOBMaleHome AddressCityStateZipPhone #Work AddressCityStateZipPhone #CellEmail2. NameDOBMaleHome AddressCityStateZipPhone #Work AddressCityStateZipPhone #CellDOBMaleHome AddressCityStateZipPhone #Work AddressCityStateZipPhone #CTCPA PHS 1-10-19Page 8 of 35FemaleEmail3. NameCellFemaleEmailInitial this page to indicate that you have provided complete and accurate information:Female
4. NameDOBMaleHome AddressCityStateZipPhone #Work AddressCityStateZipPhone #CellFemaleEmail5. NameDOBMaleHome AddressCityStateZipPhone #Work AddressCityStateZipPhone #CellFemaleEmail6. NameDOBMaleHome AddressCityStateZipPhone #Work AddressCityStateZipPhone #CellFemaleEmailK. CHILDRENNAList all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside withyou. Provide the name and contact information of the custodial parent or guardian, if other than you.1. NameMaleFemaleCustodial parent or guardian (If other than you.)AddressDOBCityContact Number2. NameMaleFemaleStateZipStateZipEmailCustodial parent or guardian (If other than you.)AddressDOBCTCPA PHS 1-10-19Page 9 of 35CityContact NumberEmailInitial this page to indicate that you have provided complete and accurate information:
3. NameMaleFemaleCustodial parent or guardian (If other than you.)AddressDOBCityContact Number4. CityContact Number5. NameEmailCustodial parent or guardian (If other than you.)AddressDOBCityContact Number6. NameMaleFemaleZipCustodial parent or guardian (If other than you.)DOBMaleFemaleStateEmailCustodial parent or guardian (If other than you.)AddressDOBCityContact NumberEmail15. REFERENCESList 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not includerelatives, employers or housemates, or other individuals listed elsewhere.A. NameAddressCityStateZipCompany / Work addressHome PhoneCityWork PhoneCellHow do you know this person? (friend, teacher, family, co-worker)CTCPA PHS 1-10-19Page 10 of 35StateZipEmailHow long have you known thisperson?Initial this page to indicate that you have provided complete and accurate information:
B. NameAddressCompany / Work addressHome PhoneWork PhoneCityStateZipCityStateZipCellEmailHow do you know this person? (friend, teacher, family, co-worker)C. NameAddressCompany / Work addressHome PhoneWork PhoneHow long have you known thisperson?CityStateZipCityStateZipCellEmailHow do you know this person? (friend, teacher, family, co-worker)D. NameAddressCompany / Work addressHome PhoneWork PhoneHow long have you known thispersonCityStateZipCityStateZipCellEmailHow do you know this person? (friend, teacher, family, co-worker)E. NameAddressCompany / Work addressHome PhoneWork PhoneCellHow do you know this person? (friend, teacher, family, co-worker)CTCPA PHS 1-10-19Page 11 of 35How long have you known thisperson?CityStateZipCityStateZipEmailHow long have you known thisperson?Initial this page to indicate that you have provided complete and accurate information:
F. NameAddressCompany / Work addressHome PhoneWork PhoneCityStateZipCityStateZipCellEmailHow do you know this person? (friend, teacher, family, co-worker)G. NameAddressCompany / Work addressHome PhoneWork PhoneHow long have you known thisperson?CityStateZipCityStateZipCellEmailHow do you know this person? (friend, teacher, family, co-worker)How long have you known thispersonSECTION 3: EDUCATIONNOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.16. Check applicable:High School DiplomaGEDDischarge documents from armed services with 2 years active duty17. List High Schools Attended or where you obtained your GED.A. NameCityStateToFromDid you graduate?B. NameYesCityNoStateToFromDid you graduate?YesNo18 List all colleges or universities attended:A. NameFromCTCPA PHS 1-10-19Page 12 of 35CityToType of Degree EarnedStateTotal Units EarnedInitial this page to indicate that you have provided complete and accurate information:
B. NameFromCityToType of Degree EarnedC. NameFromStateTotal Units EarnedCityToStateType of Degree EarnedTotal Units Earned19. List any trade, vocational, or business schools / institutes attended.A. NameFromToType of school or trainingB. NameCityFromToType of school or trainingC. NameType of school or trainingDid you complete the course?YesNoStateDid you complete the course?YesNoCityFromToStateDid you complete the course?YesNoCityStateSECTION 3: EDUCATION continued.20. Have you ever been placed on academic discipline, suspended or expelled from any high school, college/university,business or trade school?NoIf yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school oreducational institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation ofcircumstances.CTCPA PHS 1-10-19Page 13 of 35Initial this page to indicate that you have provided complete and accurate information:
SECTION 4: RESIDENCE21. LIST OF RESIDENCES List all residences during the last ten years or since age 17. Provide complete addresses (include markers suchas Street, Drive, Road, East, West, etc., and unit or apartment number). Do not use P.O. Boxes. If the residence is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LISTmilitary barracks mates unless you shared individual quarters. If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate whatquestion number and page this refers to.A. Current residence StreetCityStateZipFromToIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerCity / State / ZipContact NumberEmailNames of those with whom you liveNAB. Former AddressFromToCityIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerNACity / State / ZipStateZipContact NumberEmailNames of those with whom you lived.Reason for movingC. Former AddressFromToCityIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerNACity / State / ZipStateContact NumberEmailNames of those with whom you lived.Reason for movingCTCPA PHS 1-10-19Page 14 of 35ZipInitial this page to indicate that you have provided complete and accurate information:
D. Former AddressFromToCityIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerNACity / State / ZipStateZipContact NumberEmailNames of those with whom you lived.Reason for movingE. Former AddressFromToCityIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerNACity / State / ZipStateZipContact NumberEmailNames of those with whom you lived.Reason for movingF. Former AddressFromToCityIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerNACity / State / ZipStateZipContact NumberEmailNames of those with whom you lived.Reason for movingG. Former AddressFromToCityIf renting; property manager, rent collector or ownerAddress of property mgr., rent collector, ownerNACity / State / ZipStateContact NumberEmailNames of those with whom you lived.Reason for movingCTCPA PHS 1-10-19Page 15 of 35ZipInitial this page to indicate that you have provided complete and accurate information:
22. Provide contact information for all housemates listed in Question 21 with whom you have resided during the past 10years, or since the age of 17. DO NOT list anyone for whom you have already provided contact information. If you needadditional space for your answers, attach additional sheets as needed. Be sure to indicate what question number andpage this refers to.A. NameContact NumberCurrent Address StreetCityStateNature of relationship (friend, relative, landlord, housemate only)B. NameStreetEmailCTCPA PHS 4-2-2018Page 14 of 35Contact NumberCityNature of relationship (friend, relative, landlord, housemate only)StateContact NumberCityNature of relationship (friend, relative, landlord, housemate only)StateContact NumberCityNature of relationship (friend, relative, landlord, housemate only)StateContact NumberCityNature of relationship (friend, relative, landlord, housemate only)StateContact NumberCityNature of relationship (friend, relative, landlord, housemate only)CTCPA PHS 1-10-19Page 16 of 35ZipEmailF. NameStreetZipEmailE. NameStreetZipEmailD. NameStreetZipEmailC. NameStreetZipStateEmailInitial this page to indicate that you have provided complete and accurate information:Zip
23. Have you ever been evicted or asked to leave a residence?YesNo24. Have you ever left a residence owing rent?YesNoIf you answered yes to Questions 23 and / or 24 explain (include when, where and circumstances).SECTION 5: EXPERIENCE AND EMPLOYMENT25. JOB EXPERIENCE List ALL jobs you have had in the last ten years, including part-time, temporary, self-employment and volunteer.(Begin with your most current. If more space is needed, continue your response on page 33.) If you have military experience, including reserve duty, enter your military base, assignments, or unit ofassignment. List ALL periods of unemployment in excess of 30 days.A. Name of employer or military unit.FromAddress or BaseCitySupervisorStateContact Number Ext.Job TitleToZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersVolunteerCo-workers Phone NumberWould there be a problem if we contactyour current employer?YesNoB. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherCTCPA PHS 1-10-19Page 17 of 35TempIf yes, explain.FromBetween jobsLeave of absenceTravelInitial this page to indicate that you have provided complete and accurate information:To
C. Name of employer or military unit.FromAddress or BaseCitySupervisorStateContact Number Ext.Job TitleZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone NumberD. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherBetween jobsLeave of absenceAddress or BaseCitySupervisorToFromToStateContact Number Ext.Job TitleFromTravelE. Name of employer or military unit.ZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone NumberF. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherCTCPA PHS 1-10-19Page 18 of 35ToFromBetween jobsLeave of absenceTravelInitial this page to indicate that you have provided complete and accurate information:To
G. Name of employer or military unit.FromAddress or BaseCitySupervisorStateContact Number Ext.Job TitleToZipEmailReason for leavingDuties /AssignmentsF-TP-TTempSelf-employedNames of co-workersCo-workers Phone NumberH. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherBetween jobsLeave of absenceAddress or BaseCitySupervisorToFromToStateContact Number Ext.Job TitleFromTravelI. Name of employer or military unit.ZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone NumberJ. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherCTCPA PHS 1-10-19Page 19 of 35VolunteerFromBetween jobsLeave of absenceTravelInitial this page to indicate that you have provided complete and accurate information:To
K. Name of employer or military unit.FromAddress or BaseCitySupervisorStateContact Number Ext.Job TitleZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone NumberL. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherBetween jobsLeave of absenceAddress or BaseCitySupervisorToFromToStateContact Number Ext.Job TitleFromTravelM. Name of employer or military unit.ZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone NumberN. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherCTCPA PHS 1-10-19Page 20 of 35ToFromBetween jobsLeave of absenceTravelInitial this page to indicate that you have provided complete and accurate information:To
O. Name of employer or military unit.FromAddress or BaseCitySupervisorStateContact Number Ext.Job TitleToZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone NumberP. PERIOD OF UNEMPLOYMENTCheck applicable:StudentOtherBetween jobsLeave of absenceQ. Name of employer or military unit.Address or BaseFromToFromToTravelCitySupervisorContact Number Ext.Job TitleStateZipEmailReason for leavingDuties /AssignmentsF-TP-TSelf-employedNames of co-workersTempVolunteerCo-workers Phone Number26. Have you ever been disciplined at work? (This includes written warnings, formal letters ofreprimands, suspensions, reductions in pay, reassignments or demotions?27. Have ever you ever been fired, released from probation, or asked to resign from any place ofemployment?YesNoYesNo28. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer?YesNo29. Have you ever resigned without giving two weeks-notice?YesNo30. Have you ever resigned in lieu of termination?YesNo31. Have you ever been accused of discrimination (such as sexual harassment, racial bias,sexual orientation harassment, etc.) by a co-worker, superior, subordinate or customer?YesNoCTCPA PHS 1-10-19Page 21 of 35Initial this page to indicate that you have provided complete and accurate information:
32. Were you ever the subject of a written complaint at work?YesNo33. Have you ever been counseled at work due to lateness or absencesYesNo34. Did you ever receive an unsatisfactory performance review?YesNo35. Have you ever sold, released, or given away legally confidential information?YesNo36. Have you ever called in sick when you were neither sick nor caring for a sick family member?If yes, how many sick days have you used in the past five years which were not due to illness?YesNo37. If you answered yes to any of Questions 26–36, explain (include when, where and circumstances; indicatecorresponding number):38. Has
Police.Academy@ctcd.edu or call 254-616-3316 to make your appointment I am applying for: [ XX]Peace Officer Academy Cadet PID# [ ] County Jailer Academy Cadet PID# [ ] Telecommunicator Academy Cadet PID# POLICE ACADEMY CADET PERSONAL HISTORY STATEMENT. Personal History Statement NAME:
