Personal History Statement
Applicant's First Name, Middle Name, Last Name (Legal Name)*
Nicknames or Aliases*
Applicant's Date of Birth*
Place of Birth*
Applicant's Social Security Number*
Driver's License Number/ Expiration Date/ State of License*
Today's Date*
Street Address*
City*
State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*
Mailing Address*
Mailing City*
Mailing State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Mailing Zip Code*
Primary Contact Phone number*
Home Phone Number *
Please Provide your Arkansas CLEST number
Applicant's Height*
Applicant's Weight*
List organizations, clubs and associations of which you are or have been a member, or with which you are or have been associated.
List hobbies and/or special skills.
Name of Spouse or Fiance(e)*
If married, are you living with your spouse?* If not, state reasons
Have you ever been separated or divorced?* If yes give date and location*
Child 1 *
Child 2 *
Child 3 *
Child 4 *
Are you now supporting all children born to you, adopted by you and stepchildren?* If no, give details
List three reliable persons (not relatives or employers) who know you well enough to provide information about you. Write their first and last name, phone number, address, and occupation.
Reference 1 *
Reference 2 *
Reference 3 *
1.List your parents, brother's and sisters*
2.List your parents, brother's and sisters*
3.List your parents, brother's and sisters*
4.List your parents, brother's and sisters*
Have any members of your immediate family ever been arrested for or convicted of a felony offense?* If yes, complete the following:
Date, location, charge, disposition
Do you own or rent your own home?*
List any motor vehicles that you own or are buying or leasing *
List Credit References
1. Credit Reference *
1.Amount Owed*
2. Credit Reference *
2.Amount Owed*
3. Credit Reference *
3.Amount Owed*
List last three places of residences
Location 1 *
1.From when to when*
Landlord name and phone number*
Location 2*
2.From when to when*
3.Landlord name and phone number*
Location 3*
4.From when to when*
5.Landlord name and phone number*
Have you ever been discharged or forced to resign because of misconduct or unsatifactory service, (please explain)*
Have your employers always treated you fairly? (please explain) *
Do you object to wearing a Uniform? Duty Gear, Protective Equipment?* Do you object to working 2nd and 3rd shifts?* List the last 3 Jobs that you have held
Current or Last Employer*
1. Title*
1.Address*
1.Phone Number *
1.Supervisors Name*
1.Start Date *
1.End Date *
1.Start Salary *
1.Ending Salary *
1.May we contact this employer?* 1.Explain Duties of work*
Reason for leaving or termination*
2.*
2.Title*
2.Address*
2.Phone Number *
2.Supervisors Name*
2.Start Date *
2.End Date *
2.Start Salary *
2.Ending Salary *
2.May we contact this employer?* 2.Explain Duties of work*
2.Reason for leaving or termination*
3.*
3.Title*
3.Address*
3.Phone Number *
3.Supervisors Name*
3.Start Date *
3.End Date *
3.Start Salary *
3.Ending Salary *
3.May we contact this employer?* 3.Explain Duties of work*
3.Reason for leaving or termination*
Have you previously submitted an application with this agency (Provide Approximate Date)*
Certification- Are you currently Arkansas Certified?*
Were you ever in the U.S. Military Service or any other Military Organizations?* If yes List the Branch of Service, Unit, Date of Enlistment, Date of Discharge, Type of Discharge, Service Number, and Highest Rank
Are you presently a member of the National Guard or any other military reserve? Give unit, location, and describe your obligation.* 1. Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be in PDF, JPG, or JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking "Open". Clear the above selected file(s)
List all Schools that you have attended- Primary and College, Specialty*
Did you graduate or pass a high school equivalency test?* List all college degrees and major field of each, and or other Certifications *
Were you ever expelled from any school or disciplined by any school officials? ( If yes explain)*
2.Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be in PDF, JPG, or JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking "Open". Clear the above selected file(s)
Have you ever been arrested or detained by police? If yes explain below*
Have you ever been charged with a crime? (If yes, Explain)*
Have you ever been reported as a missing or runaway? (please give details of the incident) *
Have you ever been fingerprinted by a police agency other than for arrest? (Give details)*
What do you consider to be the current social problem of greatest concern?*
Have you ever used any controlled substances including but not limited to Marijuana, Methamphetamine, Cocaine, or Ecstasy? If yes, explain below including date of last usage. *
What are your beliefs concerning the use of alcohol, marijuana and other mind altering drugs?*
What are your feelings about the use of deadly force if it became necessary in the performance of your official duties?*
Explain briefly your reasons for applying for this position*
Where do you plan to be in the next 5 years?*
Email*
Email Confirmation*
AFFIDAVIT PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING.
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission will disqualify me from consideration. Dismissal of employment shall be mandatory if fraudulent disclosures are given to meet position qualifications. I understand that pre-employment screens are a condition of my employment. A background check of my driving, criminal, or other records including but not limited to credit reports will be conducted before employment. I will also be required to successfully pass a drug screen examination. By signing below, I consent to both a pre-employment drug and criminal background screen. I also consent to post-employment drug screens per Stone County Government Policy. I understand that as a condition of my employment, I will be required to furnish documentation verifying my identity and eligibility to work in the United States. I authorize my current and previous employers listed on my application to provide Stone County Sheriff's Office with any job-related information requested. I waive any right to legal claims against a disclosing person, employer, or institution and the prospective employer seeking and using this information for hiring purposes. Notwithstanding any provisions of Federal or State law, I also waive any right I may have to review confidential material/information received by Stone County Sheriff's Office from a person, employer, or institution. I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice. I have read, understand and by my signature, consent to these standards.
Signature*
Today's Date *
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