PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 1 OF 23
SECTION 1: PERSONAL
1. YOUR FULL NAME
LAST
FIRST
MIDDLE
2. OTHER NAMES, INCLUDING NICKNAMES YOU HAVE USED OR BEEN KNOWN BY
3. ADDRESS WHERE YOU RESIDE NUMBER/STREET
APT/UNIT
CITY
STATE
ZIP
4. MAILING ADDRESS, IF DIFFERENT FROM ABOVE
5. CONTACT NUMBERS
HOME
WORK
EXT
OTHER
CELL FAX PAGER
6. EMAIL ADDRESS
7. Are you a U.S. Citizen?
………………………………………………………………………………………………………………..………
…………………………………………………….........
YES
NO
If you were born outside of the United Sates, are you are naturalized U.S. citizen?
YES
NO
8. BIRTH PLACE (CITY/COUNTY/STATE/COUNTRY)
9. BIRTHDATE
10. SOCIAL SECURITY NUMBER
- -
11. DRIVER’S LICENSE
NO
STATE
EXP
12. PHYSICAL DESCRIPTION
HEIGHT WEIGHT HAIR COLOR EYE COLOR
13. Tattoos; scars; other identifying marks; carefully describe the nature/subject; color and location of the tattoo. If more space is needed continue your response on page 16.
SECTION 2: RELATIVES AND REFERENCES
14. IMMEDIATE FAMILY
• Provide all applicable information in the spaces below
• Circle “N/A” if a category is not applicable or if the individual is deceased. If the individual is deceased, please list his or her name.
• If more space is needed continue your response on page 22.
N/A
A. FATHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAM
E
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
B. STEP-FATHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
C. MOTHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
D. STEP-MOTHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 2 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 2 OF 23
SECTION 2: RELATIVES AND REFERENCES Continued
14. IMMEDIATE FAMILY continued
N/A
E. SPOUSE / REGISTERED DOMESTIC PARTNER / SIGNIFICANT OTHER (CIRCLE ONE)
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
DATES OF RELATIONSHIP
HOME PHONE
CELL PHONE
EMAIL
N/A
F. FATHER-IN-LAW
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
G. MOTHER-IN-LAW
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
H. FORMER SPOUSE(S) / FORMER REGISTERED DOMESTIC PARTNERS(S) / FORMER SIGNIFICANT OTHERS (CIRCLE ONE)
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
DATES OF RELATIONSHIP
HOME PHONE
CELL PHONE
EMAIL
YEAR OF DISSOLUTION
Is there, or has there ever been, a restraining or stay-away order in effect for this individual?
YES
NO
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
DATES OF RELATIONSHIP
HOME PHONE
CELL PHONE
EMAIL
YEAR OF DISSOLUTION
Is there, or has there ever been, a restraining or stay-away order in effect for this individual?
YES
NO
N/A
I. BROTHERS AND SISTERS – List all living siblings and their relation to you, including half-siblings, step-siblings, foster siblings, etc.
A) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
B) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 3 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 3 OF 23
SECTION 2: RELATIVES AND REFERENCES Continued
14. IMMEDIATE FAMILY (Section I. Brothers and Sisters) continued
C) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
D) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
E) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
J. CHILDREN
List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you. Provide the name and
contact information of the custodial parent or guardian, if other than you.
A) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
RELATION
CHILD’S AGE
M F
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
B) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
RELATION
CHILD’S AGE
M F
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
C) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
RELATION
CHILD’S AGE
M F
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
D) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
RELATION
CHILD’S AGE
M F
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
E) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
RELATION
CHILD’S AGE
M F
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
F) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
RELATION
CHILD’S AGE
M F
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 4 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 4 OF 23
15. REFERENCES
List 8-10 people who know you well, such as social and family friends, co-workers, military acquaintances. DO NOT INCLUDE relatives, employers,
housemates, co-workers, or any other individuals listed in another section.
A) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
B) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
C) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
D) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
E) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
F) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
G) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 5 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 5 OF 23
SECTION 2: RELATIVES AND REFERENCES (Question 15. References) Continued
H) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
I) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
J) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
SECTION 3: EDUCATION
Note: You will be required to furnish transcripts or other proof to support all of your educational claims.
15. CHECK APPLICABLE:
High School Diploma from an accredited U.S. Institution
GED
High School Proficiency Certificate
16. LIST HIGH SCHOOLS ATTENDED:
A) NAME
FROM (MO/YR)
TO (MO/YR)
DEGREE EARNED
CITY
STATE
B) NAME
FROM (MO/YR)
TO (MO/YR)
DEGREE EARNED
CITY
STATE
17. LIST ALL COLLEGES ATTENDED OR UNIVERSITIES ATTENDED:
A) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
CITY
STATE
B) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
CITY
STATE
C) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
CITY
STATE
18. LIST TRADE, VOCATIONAL OR BUSINESS SCHOOLS/INSTITUTES ATTENDED:
A) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
TYPE OF SCHOOL OR TRAINING
CITY
STATE
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 6 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 6 OF 23
SECTION 3: EDUCATION (Question 18. List Trade, Vocational or Business School/Institutes attended) Continued
B) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
TYPE OF SCHOOL OR TRAINING
CITY
STATE
C) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
TYPE OF SCHOOL OR TRAINING
CITY
STATE
20. Have you ever attended or are you currently attending a POST Basic Academy? ………………………………………………………
YES
NO
If you answered “YES”, provide the following information:
A) ACADEMY NAME
FROM (MO/YR)
TO (MO/YR)
DID YOU
GRADUATE?
LOCATION (CITY / STATE)
NAME OF TRAINING OFFICER / ACADEMY COORDINATOR
CONTACT NUMBER
YES
NO
B) ACADEMY NAME
FROM (MO/YR)
TO (MO/YR)
DID YOU
GRADUATE?
LOCATION (CITY / STATE)
NAME OF TRAINING OFFICER / ACADEMY COORDINATOR
CONTACT NUMBER
YES
NO
21. Have you ever been placed on academic discipline/probation, suspended or expelled from any high school, college/university, business
or trade school? (Circle the one that applies to you)………………………………………………………..……………………………...
YES
NO
If you answered “YES”, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution.
Include when the disciplinary action(s) occurred, name of school(s) and explanation of circumstances.
SECTION 4: RESIDENCE
20. LIST OF RESIDENCES:
• List all residences during the last 10 years or since the age of 15, in descending order. Provide complete addresses (include markers such as Street, Drive,
Road, East, West, etc., and the unit or apartment number). Do not use P.O. Boxes.
• If the residence is a Military Base, identify the name of the base in the address line, include nearest city, state and zip code. DO NOT LIST Military barrack
mates unless you shared individual quarters.
• If more space is needed continue your responses on page 22.
A) CURRENT ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
PRESENT
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
B) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 7 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 7 OF 23
SECTION 4: RESIDENCE Continued
C) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
D) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
E) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
F) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
G) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 8 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 8 OF 23
SECTION 4: RESIDENCE Continued
23. Provide contact information for all housemates listed in Question 22 with whom you have resided during the past 10 years, or since the age of 15. DO NOT list anyone for whom you
have already provided contact information. If more space is needed continue your response on page 22.
A) NAME
CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER/STREET/APT)
CITY
STATE
ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
B) NAME
CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER/STREET/APT)
CITY
STATE
ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
C) NAME
CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER/STREET/APT)
CITY
STATE
ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
D) NAME
CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER/STREET/APT)
CITY
STATE
ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
E) NAME
CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER/STREET/APT)
CITY
STATE
ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
F) NAME
CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER/STREET/APT)
CITY
STATE
ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
24. Have you ever been evicted or asked to leave a residence? ………………………………………………………………………………………….
YES
NO
25. Have you ever left a residence owing rent? …………………………………………………………………………………………………………..
YES
NO
If you have answered “YES” to Questions 24 and/or 25, explain (include when, where and circumstances). If more space is needed continue your response on page 22:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 9 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 9 OF 23
SECTION 6: EXPERIENCE AND EMPLOYMENT
26. JOB EXPERIENCE
• List ALL jobs you have had during the last TEN years. Including part-time, temporary, self-employment and volunteer work. Begin with your most current
employment. If more space is needed continue your response on page 22.
• If you have military experience, including Reserve duty, enter your military base, assignments or unit of assignment.
• List ALL periods of unemployment during the last TEN years.
A) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS & EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
Would there be a problem if we
contact your current employer?
YES NO
IF YES, EXPLAIN:
B) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
C) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS & EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
D) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
E) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS & EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
F) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 10 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 10 OF 23
SECTION 6: EXPERIENCE AND EMPLOYMENT Continued
G) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS &EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
H) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
I) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS &EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
J) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
K) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS &EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
L) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 11 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 11 OF 23
SECTION 6: EXPERIENCE AND EMPLOYMENT Continued
M) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS &EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
N) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
O) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS & EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
P) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL
OTHER
FROM (MO/YR)
TO (MO/YR)
Q) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR (REQUIRED)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS & EMAILS (REQUIRED)
REASON FOR WANTING TO LEAVE
1)
2)
27. Have you ever been disciplined at work? (This includes verbal/written warnings, informal/formal letters of counseling, reprimands,
suspensions, reductions in pay, reassignments or demotions) ………………………………………………………………………….......
YES
NO
28. Have you ever been fired, released from probation, or asked to resign from any place of employment? …………………………………..
YES
NO
29. Have you ever been involved in a physical or verbal altercation with a supervisor, co-worker, or customer? ……………………………..
YES
NO
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 12 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 12 OF 23
SECTION 6: EXPERIENCE AND EMPLOYMENT Continued
30. Have you ever quit without giving proper notice? ………………………………………………………………………………………..…
YES
NO
31. Have you ever resigned in lieu of termination? ……………………………………………………………………………………………..
YES
NO
32. 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? ……………………………………………………………………………………………......
YES
NO
33. Have you ever been the subject of a written complaint at work? …………………………………………………………………………...
YES
NO
34. Have you ever been counseled at work due to tardiness or absences? ……………………………………………………………………...
YES
NO
35. Have you ever received an unsatisfactory performance review? ……………………………………………………………………………
YES
NO
36. Have you ever sold, released, or given away legally confidential information? ……………………...…………………………………….
YES
NO
37. Have you ever called in sick when you were neither sick nor caring for a sick family member? ..................................................................
YES
NO
If Yes, how many sick days have you used in the past five (5) years which were not due to illness?
If you have answered “YES” to Questions 27 - 37, explain (include when, where and circumstances). If more space is needed continue your response on page 22:
38. In the past three (3) years, have you ever missed days or been late to work due to drug or alcohol consumption? ………………………..
YES
NO
If yes, how often?
39. Has your work performance ever been affected by your use of drugs or alcohol? ………………………………………………………….
YES
NO
WHEN?
NAME OF EMPLOYER
40. Have you ever been warned by an employer about your drinking or drug habits and their impact of your performance? ………………...
YES
NO
WHEN?
NAME OF EMPLOYER
41. Have you ever applied to any other law enforcement agency (city, county, state or federal)? ……………………………………………..
• If yes, list every agency you have applied to, starting with the most recent. Give complete and accurate addresses.
• All agencies must be listed regardless of the outcome or current status. Circle the steps/status as they apply for each agency.
• If more space is needed, continue your response on page 22.
YES
NO
A) NAME OF AGENCY
DATE APPLIED (MO/YR)
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process you have COMPLETED and your current status
STEPS:
APPLICATION
WRITTEN
EXAM
PHYSICAL
ABILITY EXAM
ORAL BOARD
POLYGRAPH/
CVSA
BACKGROUND
INVESTIGATION
CHIEF’S
ORAL
CONDITIONAL
JOB OFFER
STATUS:
HIRED
ON LIST
WITHDRAWN
DISQUALIFIED (DESCRIBE THE REASON
FOR THE DISQUALIFICATION)
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 13 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 13 OF 23
SECTION 6: EXPERIENCE AND EMPLOYMENT Continued
41. Have you ever applied to any other law enforcement agency…Continued
B) NAME OF AGENCY
DATE APPLIED (MO/YR)
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process you have COMPLETED and your current status
STEPS:
APPLICATION
WRITTEN
EXAM
PHYSICAL
ABILITY EXAM
ORAL BOARD
POLYGRAPH/
CVSA
BACKGROUND
INVESTIGATION
CHIEF’S
ORAL
CONDITIONAL
JOB OFFER
STATUS:
HIRED
ON LIST
WITHDRAWN
DISQUALIFIED (DESCRIBE THE REASON
FOR THE DISQUALIFICATION)
C) NAME OF AGENCY
DATE APPLIED (MO/YR)
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process you have COMPLETED and your current status
STEPS:
APPLICATION
WRITTEN
EXAM
PHYSICAL
ABILITY EXAM
ORAL BOARD
POLYGRAPH/
CVSA
BACKGROUND
INVESTIGATION
CHIEF’S
ORAL
CONDITIONAL
JOB OFFER
STATUS:
HIRED
ON LIST
WITHDRAWN
DISQUALIFIED (DESCRIBE THE REASON
FOR THE DISQUALIFICATION)
SECTION 7: MILITARY EXPERIENCE
42. Did you register for the Selective Service as required by Federal Law? …………………………………………………………………..
YES
NO
What is your Selective Service number and registration date?
Selective Service number and registration date is available at https://www.sss.gov/Registration/Check-a-Registration/Verification-Form
43. BRANCH OF SERVICE
44. DATES OF SERVICE
FROM (MO/YR) TO (MO/YR)
45. TYPE OF
DISCHARGE
ENTRY LEVEL
HONORABLE
GENERAL
OTH (OTHER THAN HONORABLE)
BAD CONDUCT
DISHONORABLE
RE-ENTRY CODE (1-4) IF APPLICABLE – REFER TO YOUR DD-214:
46. Are you currently participating in one of the following?
Military Reserve
National Guard
Date your obligation ends:
47. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as court martial, captain’s mast, office hours,
and/or company punishment)? ……………………………………………………………………………………………………………..
YES
NO
48. Were you ever denied security clearance or have you had your clearance revoked, suspended or downgraded? …………………………
YES
NO
49. Have you ever been reduced in rank as punishment? ………………………………………………………………………………………
YES
NO
If you have answered “NO” to Question 42, or if you answered “YES” to Questions 47, and/or 49, explain (include dates and circumstances). If more space is
needed continue your response on page 22:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 14 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 14 OF 23
SECTION 7: FINANCIAL
50. INCOME AND EXPENSE: For each of the following questions fill in the amounts to the nearest dollar.
A) From your employer(s), what is your TAKE-HOME monthly income? ……………………………………………………………
$
Per Month
B) What is the TAKE-HOME monthly income of your spouse or significant other? ……………………………………….……….
$
Per Month
C) Do you have any other income other than your salary or wages? …………………………………………………………………………………….
YES
NO
If “YES” fill in the amount:………………………………………………………………………………………………………..
$
Per Month
Explain:
D) How much do you spend each month? ……………………………………………………………………………………………….
$
Per Month
Estimate your monthly living expenses; include housing, utilities, credit cards or other loan repayments, food, gas, car maintenance, entertainment, etc. as well as,
any other obligations you may have.
51. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)? …………………………………………………………………………….
YES
NO
52. Have any of your bills ever been turned over to a collection agency? ….……………………………………………………………………………
YES
NO
53. Have you ever had any purchased goods repossessed? ………………………………………………………………………………………………
YES
NO
54. Have your wages ever been garnished? ……………………………………………………………………………………………………................
YES
NO
55. Have you ever been delinquent on income or other tax payments? ………………………………………………………………………………….
YES
NO
56. Have you ever failed to file income tax or cheated/lied on an income tax form? ……………………………………………………………………
YES
NO
57. Have you ever had an employment bond refused? …………………………………………………………………………………………………...
YES
NO
58. Have you ever avoided paying a lawful debt by moving away? ……………………………………………………………………………………..
YES
NO
59. Have you ever defaulted (failed to pay) on a loan? ………………………………………………………………………………………………….
YES
NO
60. Have you ever borrowed money to pay for a gambling debt? ……………………………………………………………………………………….
YES
NO
If yes, do you currently have any outstanding debts as a result of gambling? ………………………………………………………………………
YES
NO
61. Have you ever spent money for illegal purposes (e.g. illegal drugs, prostitution, purchase of fraudulent documents, etc.)? ……………………….
YES
NO
62. Have you ever failed to make or been late on a court-ordered payment (e.g. child support, alimony, restitution, etc.)? ……………………………
YES
NO
63. Have you ever knowingly written a bad check? ……………………………………………………………………………………………………...
YES
NO
If you have answered “YES” to any of Questions 51-63 explain (include when, where and why; indicate corresponding question #). If more space is needed
continue your response on page 22:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 15 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 15 OF 23
SECTION 8: LEGAL
DISCLOSURES OF ARRESTS AND CONVICTIONS
This section requires you to report detentions, arrests and convictions, including diversion programs that were not successfully completed and in some
cases offenses which may have been pardoned. It is strongly recommended you consult with an attorney before omitting any information.
64. Have you ever been detained for investigation, held on suspicion, questioned, fingerprinted, arrested, indicted, criminally charged, or
convicted of any misdemeanor or felony offense in this state or in any other legal jurisdiction (including offenses punishable under the
uniform code of Military Justice)? …………………………………………………………………………………………………………
YES
NO
If yes explain each incident in the spaces below, If more space is needed continue your response on page 22.
A) APPROXIMATE DATE (MO/YR)
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
B) APPROXIMATE DATE (MO/YR)
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
C) APPROXIMATE DATE (MO/YR)
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
65. Have you ever been placed on court probation as an adult? ………………………………………………………………………………..
YES
NO
66. Have you ever been required to appear before a juvenile court for an act which would have been a crime if committed as an adult? ……
YES
NO
67. Have you ever been a party in a civil lawsuit (e.g. divorce, small claims actions, child/spousal support, etc.)? …………………...……...
YES
NO
68. Have the police ever been called to your home for any reason? ………………………………………………………………..………..…
YES
NO
69. Have you or your spouse/partner ever been referred to Child Protective Services? ……………………………………………..………....
YES
NO
70. Do you currently have or have you ever had any association with persons convicted/charged with crimes categorized as a felony? ……
YES
NO
If yes, please provide the person’s full name, relationship, frequency of contact and charges convicted of, in the space provided.
71. Have you ever been the subject of an emergency protective order, restraining order or stay-away order? ……………………………...…
YES
NO
72. Have you settled a civil suit in which you, your insurance company, or anyone else on your behalf was required to make a payment to
another party? …........................................................................................................................................................................................
YES
NO
73. Have you ever fraudulently received welfare, unemployment compensation, worker’s compensation, or any other state or federal
assistance? …………………………………………………………………………………………………………………………………..
YES
NO
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 16 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 16 OF 23
SECTION 8: LEGAL Continued
74. Have you ever filed a false insurance or worker’s compensation claim? ………………………………………………………………...…
YES
NO
If you answered “YES” to any of Questions 65-74, explain (include court case or document(s), dates and circumstances; indicated corresponding question #). If
more space is needed continue your response on page 22:
75. INVOLVEMENT IN CRIMINAL ACTS – PART 1
Have you ever committed or been accused of the following misdemeanors? NOTE: You may not withhold any information regarding your involvement in any
of the following acts, even if federal or state law relieved you from reporting the detention, arrest or conviction that arose from it.
A) Animal abuse and/or neglect ………………………………………………………………………………………………………...………
YES
NO
B) Annoying, obscene, or harassing contacts by telephone or other electronic communication device (email, text messages, messaging
services, etc.) ……………..…………………………………………………………………………………………………………………
YES
NO
C) Battery (use of force or violence upon another) …...………………………………………………………………………………...………
YES
NO
D) Brandishing a weapon (any type of weapon) …...……………………………………………………………………………………...……
YES
NO
E) Carrying a concealed weapon without a permit …...…………………………………………………………………………………………
YES
NO
F) Contributing to the delinquency of a minor ….………………………………………………………………………………………………
YES
NO
G) Defrauding an innkeeper (not paying for food or room at a hotel/motel, campground, etc.) ..………………………………………………
YES
NO
H) Driving under the influence of alcohol and/or drugs …...……………………………………………………………………………………
YES
NO
I) Drunk in Public (being so intoxicated in a public place you are not able to care for yourself) ………………………………………………
YES
NO
J) Filed a false police report, made false statements to a police officer or 911 operator ..………………………………………………………
YES
NO
K) Hit & Run collision (no injuries) ….…………………………………………………………………………………………………………
YES
NO
L) Gambled illegally ………….…………………………………………………………………………………………………………………
YES
NO
M) Hunting or fishing illegally (example: out of season or without a license) .………………………………………………….……………
YES
NO
N) Impersonated (pretended to be) a police officer or government official .……………………………………………………………………
YES
NO
O) Indecent exposure (including flashing or mooning) and/or lewd or obscene conduct ………………………………………………………
YES
NO
P) Intentionally wrote a bad check ………………………………………………………………………………………………………………
YES
NO
Q) Joyriding (using a car or other vehicle without owner's permission)..………………………………………………………………….……
YES
NO
R) Petty larceny (value up to $650, including shoplifting/switching price tags).………………………………………………………..………
YES
NO
S) Possessed or consumed alcohol as a minor …...……………………………………………………………………………...………………
YES
NO
T) Possession of falsified or altered identification, including use of another person's ID (for any reason) ……………………………………
YES
NO
U) Possession of stolen property (including, but not limited to, vehicles, credit/debit cards) .…………………………………………………
YES
NO
V) Prostitution or solicitation of prostitution (including, patronizing illegal massage parlors) ………………………………………………...
YES
NO
W) Reckless driving …………..…………………………………………………………………………………………………………………
YES
NO
X) Resisted arrest and/or delayed or obstructed an officer (including, but not limited to, running from the police) ...…………………………
YES
NO
Y) Trespassed ……………………………………………………………………………………………………………………………………
YES
NO
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 17 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 17 OF 23
SECTION 8: LEGAL Continued
75. INVOLVEMENT IN CRIMINAL ACTS – PART 1… Continued
Z) Vandalized another's property (including, but not limited to, "tagging", malicious mischief, and/or property damage ……………………
YES
NO
AA) Voyeurism or Peeping (including, looking through a window or opening with the intent to invade someone's privacy) … ……………..
YES
NO
If you answered “YES” to ANY item(s) in Question 75, fully explain the circumstances, including date(s), names of individuals involved and resolution. Indicate the
corresponding letter (75-A, etc.) for each explanation. If more space is needed continue your response on page 22:
76. INVOLVEMENT IN CRIMINAL ACTS – PART 2
Have you ever committed or been accused of the following? NOTE: You may not withhold any information regarding your involvement in any of the
following acts, even if federal or state law relieved you from reporting the detention, arrest or conviction that arose from it.
A) Arson (Intentionally destroying property by setting a fire) ………………………………………………………………………………….
YES
NO
B) Assault with a deadly weapon (struck or threatened to strike someone with an instrument likely to cause great bodily injury or death) ….
YES
NO
C) Blackmail or extortion………………………………………………………………………………………………………………………..
YES
NO
D) Burglary (entering a structure or vehicle to commit theft or other crime) …………………………………………………………………..
YES
NO
E) Child molestation (performing unlawful acts with a child, inappropriate touching of a child) ……………………………………………...
YES
NO
F) Downloading, viewing and/or possessing child pornography ………………………………………………………………………………..
YES
NO
G) Elder abuse and/or neglect (physical and/or financial) ………………………………………………………………………………………
YES
NO
H) Embezzlement (theft of money or other valuables entrusted to you) ………………………………………………………………………..
YES
NO
I) Felony drunk driving (involving injuries or three or more convictions in a lifetime) ………………………………………………………..
YES
NO
J) Forcible rape of other act of unlawful intercourse ……………………………………………………………………………………………
YES
NO
K) Forgery (falsifying any type of document, check certificate, license, currency, etc.) ……………………………………………………….
YES
NO
L) Fraudulent use of a credit, ATM, debit, and/or check card? …………………………………………………………………………………
YES
NO
M) Grand theft (value of $651 or more, or any firearm) ………………………………………………………………………………………..
YES
NO
N) Hit & run (with injuries) ……………………………………………………………………………………………………………………..
YES
NO
O) Hate crime ……………………………………………………………………………………………………………………………………
YES
NO
P) Illegal sex acts ………………………………………………………………………………………………………………………………..
YES
NO
Q) Insurance fraud ………………………………………………………………………………………………………………………………
YES
NO
R) Murder or homicide, including attempted …………………………………………………………………………………………………...
YES
NO
S) Perjury (lying under oath) ……………………………………………………………………………………………………………………
YES
NO
T) Possession of an explosive, destructive and/or distraction device …………………………………………………………………………...
YES
NO
U) Robbery (theft from another person using a weapon, force or fear) …………………………………………………………………………
YES
NO
V) Stalking ………………………………………………………………………………………………………………………………………
YES
NO
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 18 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 18 OF 23
SECTION 8: LEGAL Continued
76. INVOLVEMENT IN CRIMINAL ACTS – PART 2… Continued
W) Theft of a vehicle and/or vehicle parts ………………………………………………………………………………………………………
YES
NO
If you answered “YES” to ANY item(s) in Question 76, fully explain the circumstances, including date(s), names of individuals involved and resolution. Indicate the
corresponding letter (76-A, etc.) for each explanation. If more space is needed continue your response on page 22:
SECTION 9: DRUG USE
Questions 77 and 78 relate to your current and past recreational drug use. This covers the use of any drug, including the unauthorized use of prescription or over-the-
counterdrugs. Your answers should include, but not be limited to, your use of any of the following drugs:
AMPHETAMINES /
METHAMPHETAMINES
(UPPERS, SPEED, CRANK, ETC.)
HALLUCINOGENS
(PEYOTE, LSD, MUSHROOMS)
PHARMACEUTICAL DRUGS NOT
PRESCRIBED TO YOU
BARBITURATES (DOWNERS)
HASHISH / HASHISH OIL
PCP / ANGEL DUST
COCAINE / CRACK COCAINE
HEROIN / OPIUM
QUAALUDES
DESIGNER DRUGS
(ECSTASY, SYNTHETIC HEROIN, ETC.)
MARIJUANA
STEROIDS
GHB
(DATE RAPE DRUG)
MESCALINE
TETRAHYDROCANNABINOL (THC)
GLUE
MORPHINE
OTHER ILLEGAL OR CONTROLLED
SUBSTANCES
77. In your lifetime, have you used any drug(s) as indicated above? …………………………………………………………..……………
YES
NO
If you answered “YES” to question 57, give details, including drug(s) used, dates used and the circumstances involved:
78. I have never used any drugs…………………………………………………………………………………………………………………
YES
NO
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 19 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 19 OF 23
SECTION 9: DRUG USE Continued
79. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including marijuana?
SOLD
PURCHASED
CULTIVATED
MANUFACTURED
FURNISHED
CARRIED OF HELD FOR ANOTHER
If you circled any of the items above, give details including drug(s) involved, over what time period’s and circumstances:
SECTION 10: MOTOR VEHICLE OPERATION
80. CURRENT DRIVER’S LICENSE NUMBER
STATE OF ISSUE
EXPIRATION DATE
NAME UNDER WHICH LICENSE WAS GRANTED
81. LIST OTHER STATES WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE:
STATE OF ISSUE
TYPE OF LICENSE
NAME UNDER WHICH LICENSE WAS GRANTED AND NUMBER IF KNOWN
82. Have you ever been refused a driver’s license by any state? ……………………………………………………………………………….
YES
NO
If you have answered “YES”, explain (include when, where and circumstances):
83. Has your driver’s license ever been suspended or revoked? …………………………………………………………………………...…..
YES
NO
If you have answered “YES”, explain (include when, where and circumstances):
84. List your current liability insurance on your vehicle(s)
A) TYPE OF COVERAGE
INSURED BONDED CASH DEPOSIT
VEHICLE MAKE
YEAR
VEHICLE LICENSE/STATE
INSURANCE COMPANY
POLICY NUMBER
EXPIRATION DATE
ADDRESS (NUMBER / STREET) CITY STATE ZIP
CONTACT NUMBER
B) TYPE OF COVERAGE
INSURED BONDED CASH DEPOSIT
VEHICLE MAKE
YEAR
VEHICLE LICENSE/STATE
INSURANCE COMPANY
POLICY NUMBER
EXPIRATION DATE
ADDRESS (NUMBER / STREET) CITY STATE ZIP
CONTACT NUMBER
C) TYPE OF COVERAGE
INSURED BONDED CASH DEPOSIT
VEHICLE MAKE
YEAR
VEHICLE LICENSE/STATE
INSURANCE COMPANY
POLICY NUMBER
EXPIRATION DATE
ADDRESS (NUMBER / STREET) CITY STATE ZIP
CONTACT NUMBER
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 20 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 20 OF 23
SECTION 10: MOTOR VEHICLE OPERATION Continued
85. List all traffic citations you have received since the age of 18. Include citations you have had amended or reduced to parking violation. Provide copies of citations or
court documents for the violation. If more space is needed, continue your response on page 22.
A) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED
ACTION TAKEN (CIRCLE ALL THAT APPLY)
MONTH
YEAR
NOT GUILTY
FINED
TRAFFIC SCHOOL
DISMISSED
B) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED
ACTION TAKEN (CIRCLE ALL THAT APPLY)
MONTH
YEAR
NOT GUILTY
FINED
TRAFFIC SCHOOL
DISMISSED
C) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED
ACTION TAKEN (CIRCLE ALL THAT APPLY)
MONTH
YEAR
NOT GUILTY
FINED
TRAFFIC SCHOOL
DISMISSED
D) Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following? (Circle all that apply)
FAILURE TO APPEAR
FAILURE TO COMPLETE TRAFFIC SCHOOL
FAILURE TO PAY THE REQUIRED FINE
If circled, explain circumstances:
85. Have you been involved as the driver in a motor vehicle accident with the past ten (10) years? ………………………………………….
YES
NO
If yes, give details below and include any accidents reports:
A) DATE
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY
NON-INJURY
B) DATE
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY
NON-INJURY
C) DATE
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY
NON-INJURY
86. Have you ever driven a vehicle without automobile insurance as required by law? ………………………………………………………..
YES
NO
If you have answered “YES”, give reason:
DATE VIOLATION OCCURRED
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
MONTH
YEAR
87. Have you ever been refused automobile liability insurance or a bond or had them cancelled? …………………………………………..
YES
NO
If you have answered “YES”, give reason:
INSURANCE COMPANY
DATE VIOLATION OCCURRED
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
MONTH
YEAR
Use this space for additional information you would like to include regarding your driving record:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 21 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 21 OF 23
SECTION 11: OTHER TOPICS
88. Do you currently have a concealed weapon permit?.......................................................................................................................................
YES
NO
89. Have you ever been refused a concealed weapon permit? ………………………………………………………………………………….
YES
NO
90. Are you now or have you ever been, a member or associate of a criminal enterprise, street gang or any other group which advocated
violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality, gender, sexual preference or
disability? …………………………………………………………………………………………………………………………………...
YES
NO
91. Do you have, or have you ever had, a tattoo signifying membership in or affiliation with a criminal enterprise, street gang or any other
group which advocated violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,
gender, sexual preference or disability? …………………………………………………………………………………………………….
YES
NO
92. Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or violent act?.................................
YES
NO
93. Have you ever hit or physically overpowered a spouse or romantic partner? ………………………………………………………………
YES
NO
If you have answered “YES” to any of Questions 88-93, give details including dates and circumstances; identify the corresponding question being referenced:
SECTION 11: CERTIFICATION
93. I hereby certify I have personally completed each page of this form and any supplemental page(s) attached and all statements made are true and complete to the best
of my knowledge and belief. I understand any misstatement of material fact may subject me to disqualification or if I have been appointed, may disqualify me from
continued employment.
SIGNATURE IN FULL
DATE
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 22 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 22 OF 23
SECTION 11: ADDITIONAL SPACE
Use this space to provide information that does not fit elsewhere on this form (e.g. additional family members, schools, residences, employers, explanations to
questions, etc.). Identify the corresponding question and specific item number being referenced.
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 23 of 34
PERSONAL HISTORY STATEMENT – SWORN APPLICANT
PAGE 23 OF 23
Please complete this page in your own handwriting.
Question: “Why do you want this job? How do you think it will benefit you and the agency?”
PENALTY AND CERTIFICATION
I HEREBY CERTIFY THERE ARE NO WILLFUL MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS IN THE FOREGOING STATEMENTS AND
ANSWERS TO THE QUESTIONS. ALL STATEMENTS AND ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER
UNDERSTAND FALSIFYING, WITHHOLDING OR FAILING TO ANSWER ANY AND ALL QUESTIONS COMPLETELY AND ACCURATELY MAY
CAUSE REJECTION FROM CONSIDERATION FOR THE POSITION TO WHICH I AM APPLYING.
SIGNATURE
DATE
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 24 of 34
REQUIRED DOCUMENT AGREEMENT-SWORN
All Agreements and Documents are required. If any documentation cannot be obtained, you must
provide a full explanation in writing of the effort made to obtain and why you did not. By failing to do
so, you may be disqualified from further consideration.
All Agreements listed are required – for eSOPH users, upload into the Agreements section
1. Pre-Employment Waiver and Liability – Notary Required
2. Nevada Dept. of Corrections Waiver – Notary Required
▪ 2 pages. If you were not employed by NDOC, then you only Sign, Date, and Print Name on page 1, then
have page 2 notarized. If you are/were employed by NDOC, complete the full form. DO NOT FAX THIS
WAIVER.
3. Military Waiver – You must complete Name, SSN, Date of Birth, Place of Birth and Signature
▪ If you were or currently are in the military, complete the entire form
4. Child Support Waiver – POST ID is only applicable if you are already Nevada POST Certified
5. Fingerprint Request Form – Completed and Signed by the official person taking prints.
▪ If you live outside the state of Nevada – Mail the hard copy fingerprint cards to:
Nevada DPS-Backgrounds | 555 Wright Way | Carson City, Nevada 89701
6. Fingerprint Background Waiver – 2 pages
7. Required Document List (this form)
All Documents listed are required – for eSOPH users, upload into the Documents section
Name the following Documents as underlined when uploading into eSOPH** **
1. BIRTH CERTIFICATE – Upload an original copy of your birth certificate or other official proof of birth
2. APPLICATION – Upload a copy of your Success Factors application. To access this, log into Success Factors, click
Careers, then My Candidate Profile. Download and save a PDF copy. If you experience issues obtaining this, please contact
Jose Villa at (702) 486-3046 as the background unit will not be able to access this system to provide guidance.
3. AUTO INSURANCE – Declaration page(s) providing coverage details and all covered drivers for the vehicle. This is NOT
the card carried in the vehicle. Contact your agent for assistance in obtaining this document.
4. CREDIT REPORT – A full credit report, to include all payment history. Obtain a free copy of your full credit report at
www.annualcreditreport.com
5. HS TRANSCRIPT – Certified high school or GED transcript from all schools attended, regardless of duration. Must be sent
by the school or distributor to b[email protected]v.us, or mailed directly to: Nevada DPS-Backgrounds | 555 Wright
Way | Carson City, Nevada 89701 (this will be uploaded by the Background Unit)
All Images listed are required – for eSOPH users, upload into the Images section
1. HEADSHOT – Clear headshot, directly facing camera. Must be taken in last 24 hours.
2. TATTOO(s) – Clear photos of EACH tattoo and/or branding you have.
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 25 of 34
Additional Documents – for eSOPH users, upload into the Documents section
**Name the following Documents as underlined when uploading into eSOPH**
The following documents may not apply to you; however, if you fail to provide any of the following documents and
it is discovered that they do apply, you may be disqualified from further consideration.
1. NATURALIZATION – Original copy of Naturalization Certificate/Document
2. COLLEGE TRANSCRIPT – Certified college transcript from all schools attended, regardless of duration. Must be sent by
the school or distributor to background@dps.state.nv.us, or mailed directly to: Nevada DPS-Backgrounds | 555 Wright Way |
Carson City, Nevada 89701 (this will be uploaded by the Background Unit)
3. HS DIPLOMA/GED – Copy of high school diploma or GED Certificate (only if you have access to it)
4. COLLEGE DIPLOMA – Copy of college diplomas or degrees (only if you have access to it)
5. SELECTIVE SERVICE – Proof of registration, generally required for male citizens or immigrants living in the US. Visit
www.sss.gov and click “Check Registration” to obtain this.
6. DD214 – If you served in the military
7. POST – If you are POST certified in this state, or any other jurisdiction
8. MARRIAGE – Marriage certificate for each marriage
9. DIVORCE – Dissolution/Annulment documents for each divorce
10. POLICE – All reports where you are named in any capacity (victim, suspect, person of interest, or similar). If previously
employed in law enforcement, do not provide reports where you are named in relation to your legitimate, official duties of a
non-negative manner.
11. COURT - All records where you are named in any capacity (victim, suspect, person of interest, or similar). If previously
employed in law enforcement, do not provide reports where you are named in relation to your legitimate, official duties of a
non-negative manner.
12. LICENSE – All professional licenses/permits (private investigator, security guard, or similar), including CCW.
13. TPO – Copy of any Order issued or filed against you (Emergency, Protection, Restraining, Stay Away, or similar)
14. BANKRUPTCY – Discharge paperwork for each bankruptcy filed
15. BUS TAX – Forms 1065 and Schedule K-1 for any business type you have/had ownership in the past 10 years.
16. OTHER – Any other documentation, including certificates, awards, commendations, or similar.
CERTIFICATION
I certify that I have read, understand, and have not omitted any information as required above.
Signature: Date:
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 26 of 34
Human Resources
555 Wright Way
Carson City, NV 89701
PRE-EMPLOYMENT WAIVER AND
LIABILITY
RELEASE
In consideration for the processing of my application for
the position of
(Position)
,
with the I,
Agency) (Applicant Name)
. ,
(
do hereby irrevocably agree to the following:
WAIVER OF LIABILITY
I hereby release from liability and promise to hold harmless under and all causes of legal action, the State
of Nevada,
the Department of Public Safety, its agents or employees, and any and all persons or entities in
the pursuance of my
background investigation.
RELEASE OF INFORMATION
I authorize, for a period of two (2) years from the date of signature on this document, any person or entity
contacted by
the State of Nevada, the Department of Public Safety, its agents or employees, during the
course of my background
investigation, to furnish to said persons or entities, any and all information that
they may have concerning me,
including, but not limited to, written examinations, physical agility tests,
interviews, background investigations,
polygraph or other lie detection device results, psychological
evaluations, any confidential or privileged
information, employment personnel files, any sealed data or
materials, or agreed to be withheld information
pursuant to any prior agreement or court proceeding
involving disciplinary matters or any other information or
opinions they may have.
NRS 239B STATES THAT UPON REQUEST OF A LAW ENFORCEMENT AGENCY, AN EMPLOYER SHALL PROVIDE
TO THE LAW ENFORCEMENT AGENCY INFORMATION, IF AVAILABLE, REGARDING A CURRENT OR FORMER
EMPLOYEE OF THE EMPLOYER WHICH IS AN APPLICANT FOR THE POSITION OF PEACE OFFICER WITH THE
LAW ENFORCEMENT AGENCY. FURTHERMORE, NRS 41.755 STATES…AN EMPLOYER WHO DISCLOSES
INFORMATION REGARDING AN EMPLOYEE TO A LAW ENFORCEMENT AGENCY PURSUANT TO SECTION 1
OF THIS ACT IS IMMUNE FROM CIVIL LIABILITY FOR SUCH DISCLOSURE AND ITS CONSEQUENCES.
INVESTIGATION DISCOVERY WAIVER
Pursuant to NAC 284.718 and NAC 284.726, confidentiality is imperative. Therefore, I hereby waive,
without
reservation, any right I may have, now or in the future, to examine, review or otherwise discover
the contents of this
background investigation and all related documents thereto. This waiver shall apply
to any right of action of any
nature whatsoever, that may accrue to myself, my heirs, or my personal
representative(s).
Dated this day of ,
Signature of Person Waiving Rights
Subscribed and Sworn before me this day of ,
Signature of Notary (Notary Seal)
Notary public in and for said county of State of
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 27 of 34
REQUEST PERTAINING TO MILITARY RECORDS
Requests from veterans or deceased veteran’s next-of-kin may be submitted online by using eVetRecs at http://www.archives.gov/veterans/military-service-records/
To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW
SECTION I – INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible)
1. NAME USED DURING SERVICE (last, first, full middle)
2. SOCIAL SECURITY #
3. DATE OF BIRTH
4. PLACE OF BIRTH
5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.)
BRANCH OF SERVICE
DATE
ENTERED
DATE
RELEASED
OFFICER
ENLISTED
SERVICE NUMBER
(If unknown write “unknown”)
a. ACTIVE
☐
☐
b. RESERVE
☐
☐
c. STATE
NATIONAL
GUARD
☐
☐
6. IS THIS PERSON DECEASED?
☐NO
☐YES – MUST PROVIDE Date of Death if veteran is deceased:
7. DID THIS PERSON RETIRE FROM MILITARY SERVICE?
☐NO
☐YES
SECTION II – INFORMATION AND/OR DOCUMENTS REQUESTED
1. CHECK THE ITEM(S) YOU ARE REQUESTING:
☒ DD 214 Form or equivalent. Year(s) in which form (s) issued to veteran:
This form contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran’s next-of-kin, or other persons or organizations, if
authorized in Section III, below. An UNDELETED DD214 is ordinarily required to determine eligibility for benefits. If you request a DELETED copy, the following items will be
blacked out. Authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and, for separations after June 30, 1979, character of separation and
dated of time lost.
An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box: ☐ I want a DELETED copy.
☐ Medical Records Includes Service Treatment Records, Health (outpatient) and Dental Records. IF HOSPITALIZED (inpatient) the FACILITY NAME and
Date (month and year) for EACH admission MUST be provided:
☒ Other (Specify):
ALL DOCUMENTS IN OFFICIAL MILITARY PERSONNEL FILE (OMPF)
2. PURPOSE: (Providing information about the purpose of the request is strictly voluntary; however, it may help to provide the best possible response and may result in a faster reply. Information
provided will in no way be used to make a decision to deny the request.)
☐ Benefits (explain)
☐Employment
☐VA Loan Program
☐Medical
☐Genealogy
☐Correction
☐Personal
☐Other (explain)
Explain here:
PRE-EMPLOYMENT BACKGROUND INVESTIGATION
SECTION III – RETURN ADDRESS AND SIGNATURE
1. REQUESTER NAME:
2. ☒ I am the MILITARY SERVICE MEMBER OR VETERAN identified in Section
I above.
☐I am the VETERAN’S LEGAL GUARDIAN (MUST submit copy of
Court
Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit
copy of Authorization Letter or Power of Attorney)
☐ I am the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit Proof of
Death. See item 2A on instructions sheet.)
☐OTHER
(Relationship to deceased Veteran)
(Specify type of Other)
3. SEND INFORMATION/DOCUMENTS TO:
(Please print of type. See item 4 on accompanying instructions.)
4. AUTHORIZATION SIGNATURE: I declare (or certify, verify, or state) under penalty of
perjury under the laws of the United States of America that the information in this Section
III is true and correct and that I authorize the release of the requested information. (See
items 2a or 3a on accompanying instruction sheet. Without the Authorization Signature of the
veteran, next-of-kin of deceased veteran, veteran’s legal guardian, authorized government agent,
or other authorized representative, only limited information can be released unless the request is
archival. No signature id required if the request is for archived records.)
NEVADA DPS, BACKGROUNDS INVESTIGATION UNIT
Name
555 WRIGHT WAY
Street
CARSON CITY
NV
89701
City
State
Zip Code
Signature Required – Do Not Print
Date
* This form is available at http://www.archives.gov/veterans-military-service-
records/standard-form-180.pdf on the National Archives and Records Administration
(NARA) web site.*
Daytime Phone
Fax Number
Email Address
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 28 of 34
Veteran Status, Child Support Statement and Personal Affirmation 07/16/2015
STATE OF NEVADA
COMMISSION ON PEACE OFFICERS’ STANDARDS AND TRAINING
5587 Wa Pai Shone Avenue
Carson City, Nevada 89701
(775) 687-7678 Fax (775) 687-4911
VETERAN STATUS, CHILD SUPPORT STATEMENT AND PERSONAL AFFIRMATION
➢This document must be retained on file by the employing agency for inspection and must include the social security
number of the applicant (NRS 289.560)
Make a copy of this document and redact the first 5 numbers of the social security number showing only the last 4
digits of the social security number and submit as an attachment to the Basic Certificate Application (Formatta form).
➢
Veteran Status
Are you a Military Veteran? YES NO☐ ☐
Statement Regarding Payment of Child Support
Pursuant to NRS 289.570 and NRS 425.520, you are required to mark one of the following three choices.
I am not subject to a court order for the support of one or more children.
I am subject to a court order for the support of one or more children and I am in compliance with the order or a plan
approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed
pursuant to the order; or
I am subject to a court order for the support of one or more children and I am NOT in compliance with the order or a
plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed
pursuant to the order.
☐
☐
☐
Personal Affirmation
I hereby affirm that I have reviewed the contents of this document and agree that the information is true and accurate. I
further affirm, as the applicant for basic certification as a Nevada peace officer, that I am currently a US citizen, 21 years
of age or older, and that I have met all requirements of NAC 289.110 (Standards of Appointment); and, I understand that
any misrepresented information is grounds to refuse or revoke my Basic Certificate pursuant to NAC 289.290.
Applicant’s Social Security Number POST ID#_______________________ _______________
Applicant’s Name:
Type or Print Name First MI Last Suffix
____________________________ _____ ______________________________ ____
Signature of Applicant Date__________________________________________ ______________
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 29 of 34
BOARD OF
COMMISSIONERS
STEVE SISOLAK
Governor
BARBARA CEGAVSKE
Secretary of State
ADAM PAUL LAXALT
Attorney General
Northern Administration
5500 Snyder Avenue, Carson City, NV 89702
Phone: (775) 887-3285 - Fax: (775) 887-3138
Southern Administration
3955 W. Russell Road, Las Vegas, NV 89118
Phone: (702) 486-9938 - Fax: (702) 486-9961
Steve Sisolak
Governor
James Dzurenda
Director
Please fax request to 702-486-9955
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request a law enforcement clearance letter (IAB); this letter should contain information regarding any
PREA/Criminal and/or Internal Investigations where I was the subject. This information will include all investigations. I
understand I may not have yet received notification of current investigations pursuant to NRS 289.060. I understand I will
not be able to obtain any information from Human Resources and/or the Inspector General’s Office about any current
investigations, where I am the subject, until the investigation has been closed.
This Authorization for Release of Information is for outside law enforcement agencies. No personal copies will be
provided. Notarized waiver must be included in all release requests.
I understand this information will be forwarded to the requested law enforcement agency within 3-5 business days.
Signature Date
Print Name Work Location Emp. ID Number
Name of Law Enforcement Agency/Agent:
Nevada Department of Public Safety-Backgrounds
Mail request to following address:
555 Wright Way, Carson City, Nevada 89701
E-mail request to the following address (if accepted):
WAIVER OF LIABILITY
I hereby release from liability and promise to hold harmless under and all causes of legal action, the State of Nevada, the
Department of Corrections, its agents or employees, and any and all persons or entities in the pursuance of my background
investigation.
RELEASE OF INFORMATION
I authorize, for a period of one (1) year from the date of signature on this document, the State of Nevada, Department of
Corrections, its agents or employees, during the course of my background investigation, to furnish NEVADA
DEPARTMENT OF PUBLIC SAFETY – BACKGROUND INVESTIGATION UNIT, any and all information that they
may have concerning me, including, but not limited to, any confidential or privileged information, employment personnel
files, any sealed data or materials, or agreed to be withheld information pursuant to any prior agreement or court
proceeding involving disciplinary matters or any other information or opinions they may have.
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 30 of 34
INVESTIGATION DISCOVERY WAIVER
Pursuant to NAC 284.718 and NAC 284.726, confidentiality is imperative. Therefore, I hereby waive, without
reservation, any right I may have, now or in the future, to examine, review or otherwise discover the contents of this
background investigation and all related documents thereto. This waiver shall apply to any right of action of any nature
whatsoever, that may accrue to myself, my heirs, or my personal representative(s).
Dated this day of
Signature of Person Waiving Rights
______ ____________, ______
_________________________________________
Subscribed and Sworn before me this day of
Signature of Notary (Notary Seal)
Notary public in and for said county of
State of
___________ ______________________________________________________________________,
_____________________________________
___________________
_________________________________
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 31 of 34
Fingerprint Request Form
Please provide this form to the fingerprint technician/official at the time your fingerprints are taken to ensure all fields
contain the required/authorized information needed for processing. Save the original hardcopy as you may be asked for it
at a later time.
Call (775) 684-4836 for the account number (MNU) and ORI prior to making your appointment.
APPLICANT INFORMATION:
APPLICANT NAME: (LAST, FIRST, MI)
APPLICANT ADDRESS:
CITY, STATE, ZIP CODE:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
DATE OF BIRTH: PLACE OF BIRTH:
SSN: CITIZENSHIP:
SEX: RACE: HGT: WGT: EYES: HAIR:
ACCOUNT NUMBER (MNU): ORI:
REASON FINGERPRINTED: CRIMINAL JUSTICE APPLICANT
SUBMIT FINGERPRINT ELECTRONIC LIVESCAN: YES: NO:
FINGERPRINT SITE INFORMATION:
TCN:
________________________ __________________________
___________________________________ ______________________________
_______ ________ ________ ________ ________ ________
________________________ ________________________
________ ________
_________________________________________________________________________________________
_________________________________________________ ____________________
SIGNATURE OF OFFICIAL TAKING PRINTS DATE
The above-named individual was fingerprinted and said prints will be sent electronically to the Central Repository for Nevada Records of Criminal
History on behalf of the State of Nevada Department of Public Safety.
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 32 of 34
Below are locations within Nevada where you can have your fingerprints taken at no charge.
Call (775) 684-4836 for the account number (MNU) and ORI prior to making your appointment.
NORTHERN NEVADA
Records, Communications & Compliance Division
Fingerprint Unit
(775) 684-6262
333 West Nye Lane
Carson City, Nevada 89706
Parole and Probation Office
(775) 684-2300 | [email protected]
475 Valley Road
Reno, Nevada 89512
Special Instruction: Appointment Required – NO CHILDREN ALLOWED
SOUTHERN NEVADA
Parole & Probation – DONS Unit
(702) 486-5176
215 East Bonanza Road
Las Vegas, NV 89101
RURAL AND NON-NEVADA RESIDENTS
If you reside outside the state of Nevada or cannot make it to one of the above-mentioned locations, please visit
your local law enforcement agency. Note that there may be a charge for this service. Send the hard copy (card
provided by the law enforcement agency) to the following address-MUST BE ADDRESSED EXACTLY FOR
PROPER ROUTING:
Nevada DPS – Background Unit
555 Wright Way
Carson City, Nevada 89701
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 33 of 34
Fingerprint Background Waiver
As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal
justice purpose (such as an application for employment or a license, an immigration or naturalization matter,
security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided
to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.)
Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12, among other authorities.
1. You must be notified by Nevada DPS – Background Unit__ (name of requesting agency) that your
fingerprints will be used to check the criminal history records of the FBI and the State of Nevada.
_ ________
2. Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is
generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental
authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders,
and federal regulations. Providing your fingerprints and associated information is voluntary; however,
failure to do so may affect completion or approval of your application.
3. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be
predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible agency,
and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next
Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent
fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible
agency. The FBI and/or the Central Repository for Nevada Records of Criminal History may retain your
fingerprints and associated information/biometrics in NGI after the completion of this application and, while
retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained
by NGI.
4. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and
associated information/biometrics are retained in NGI and/or Central Repository for Nevada Records of
Criminal History, your information may be disclosed pursuant to your consent, and may be disclosed without
your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at
any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine
Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized
non-governmental agencies responsible for employment, contracting, licensing, security clearances, and
other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice
agencies; and agencies responsible for national security or public safety.
5. If you have a criminal history record, you should be afforded a reasonable amount to time to correct or
complete the record (or decline to do so) before the officials deny you the employment, license, or other
benefit based on information in the FBI criminal history record. The procedures for obtaining a change,
correction, or update of your FBI criminal history record as set forth at, 28 CFR 16.34 provides for the proper
procedure to do so.
Applicant:
Initial Date
__________________ ___________________
Updated 03-07-2022 STEVENS Full Sworn Background Packet Pg. 34 of 34
6. If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for
review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you
may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this
process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks and
https://www.edo.cjis.gov.
7. If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send
your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may
send your challenge directly to the FBI by submitting a request via https://www.edo.cjis.gov. The FBI will
then forward your challenge to the agency that contributed the questioned information and request the
agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency,
the FBI will make any necessary changes/corrections to your record in accordance with the information
supplied by that agency. (See 28 CFR 16.30 through 16.34.)
8. You have the right to expect that officials receiving the results of the fingerprint-based criminal history
record check will use it only for authorized purposes and will not retain or disseminate it in violation of
federal or state statute, regulation or executive order, or rule, procedure or standard established by the
National Crime Prevention and Privacy Compact Council.
9. I hereby authorize _Nevada DPS – Background Unit_ (name of requesting agency), to submit a set of
my fingerprints to the Nevada Department Public Safety, Records Bureau for the purpose of accessing and
reviewing State of Nevada and FBI criminal history records that may pertain to me.
_________
10. I hereby release from liability and promise to hold harmless under any and all causes of legal action, the State
of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and
provided information to the submitting agency for any statement(s), omission(s), or infringement(s) upon
my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons,
firms, institutions or agencies providing such information to the State of Nevada on the basis of their
disclosures. I have signed this release voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar process, shall for
all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature voluntarily appears
below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEASE PRINT Last Name First Name Middle
Applicant’s Signature:
Date:
Agency Account #:
Agency Representative:
PLEASE PRINT Last Name First Name Middle
Agency Representative Signature:
Date:
