Explorer Personal History Statement - Santa Barbara County ...

SANTA BABARA COUNTY SHERIFF’S DEPARTMENT
EXPLORER PERSONAL HISTORY STATEMENT
The attached Explorer Personal History Statement must be completed in black ink in the
applicant’s own printing and returned to:
Santa Barbara County Sheriff’s Department
Attention: Becky Grant
812-A W. Foster Road
Santa Maria, CA 93455
Special consideration should be given to the following areas:
1. All addresses must be complete, including entire street addresses, cities, states, and
zip codes. (Please include Street, Drive, Avenue, etc.)
2. All telephone numbers must include area codes.
3. Do not use a person’s name more than once; i.e., reference and employer).
4. All questions are to be answered. If the question does not apply to you, then print
“N/A” in the space provided, which will indicate that you have read the question.
5. Questions regarding the use of illegal drugs must be answered with the total number
of possessions and the time frame as close as you can estimate.
6. All criminal activity, whether as an adult or juvenile, must be listed.
7. If this Explorer Personal History Statement is incomplete or poorly prepared, your
application will be disqualified.
9. If additional space is needed for any answers, please attach extra sheets.
INTENTIONAL DECEPTION, OR ANY OMISSION OF A MATERIAL FACT, WILL
RESULT IN IMMEDIATE DISQUALIFICATION.
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SANTA BABARA COUNTY SHERIFF’S DEPARTMENT
EXPLORER PERSONAL HISTORY STATEMENT
ALL INFORMATION IS TO BE PRINTED IN BLACK INK
POSITION: __________________________________
DATE: _______________
PERSONAL:
1. Your Name: _____________________________________________________
First Middle Last
2. List any other name(s) you have used or have been known by, including maiden
or “nicknames”: __________________________________________________
3. Your address: ____________________________________________________
Number Street City
4. Phone #s: Home ________________________________________________
Work ________________________________________________
Pager ________________________________________________
Cellular _______________________________________________
Email address: _________________________________________
5. Date of Birth: _____________________________________________________
Month Day Year Age
6. Place of Birth: ____________________________________________________
City State County
7. Social Security #: _______________ Driver’s License #: ________________
8. Height: _______ Weight: ________ Eyes: __________ Hair: ___________
9. Are you a citizen of the United States? Yes ____________ No ____________
10. With whom do you reside? __________________________________________
Name
Relationship
11. Full name of spouse, significant other, or parent (circle one):
________________________________________________________________
Social Security #: _________________ Date of Birth: ____________________
Address: ________________________________________________________
Home Phone: ____________________ Work Phone: ____________________
Employer: _______________________ Occupation: _____________________
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EMPLOYMENT:
SANTA BABARA COUNTY SHERIFF’S DEPARTMENT
EXPLORER PERSONAL HISTORY STATEMENT
What is your occupation?: ________________________________________________
Beginning with your most current employment, list all jobs you have held in the past five
(5) years (including part-time, temporary, and volunteer positions).
Use the following format: Dates/Name of Employer/Complete Street Address/Phone
Number of Employer/Duties.
1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
4.____________________________________________________________________
5.____________________________________________________________________
RELATIONSHIP WITH PAST AND PRESENT EMPLOYERS:
Have you ever been terminated or asked to resign for any reason?
Yes: _____ No: _____ If “yes,” please explain: ____________________________
______________________________________________________________________
Have you ever quit a job in lieu of being terminated or without giving notice?
Yes: _____ No: _____ If “yes,” please explain: ____________________________
______________________________________________________________________
EDUCATION:
List schools attended or attending (if currently attending high school, middle school,
please note GPA):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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LEGAL BEHAVIOR:
SANTA BABARA COUNTY SHERIFF’S DEPARTMENT
EXPLORER PERSONAL HISTORY STATEMENT
List all law enforcement contacts you have had, including arrests, detentions, field
interviews, and questioning:
Offense
(Arrest
or
Citation)
Date/Place
Of
Arrest or
Citation
Describe Specific
Original
Arrest/Citation
Charge
If Original Charge
was Changed,
Give Conviction
Charge
Probation Length
&
Name/Address of
Probation Officer
Have you ever committed a crime which was undetected or unreported to a law
enforcement agency? Yes: _____ No: _____ If “yes,” please explain:
______________________________________________________________________
______________________________________________________________________
Are you now or have you ever been a plaintiff or defendant in any civil court action?
Yes: _____ No: _____ If “yes,” please explain:
______________________________________________________________________
______________________________________________________________________
Have you ever illegally possessed or otherwise been involved in any illegal activity,
involving the following substances? (Possession includes the mere holding, using,
experimenting with, inhaling, ingesting, smoking, injecting, or being under the influence.)
Fully explain all “yes” answers: ___________________________________________
______________________________________________________________________
Item Yes No Date Last
possessed
Marijuana
Hashish/Hash Oil
Cocaine
Barbiturates
Methamphetamine
Amphetamine
Heroin
LSD (Hallucinogenics)
PCP (Angel Dust)
Steroids
Rhypnol (Roffies/GHB)
Inhalants(glue/paint/etc.)
Ecstasy
Total
Possessions
Investigator’s
Comments
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SANTA BABARA COUNTY SHERIFF’S DEPARTMENT
EXPLORER PERSONAL HISTORY STATEMENT
Do you possess a driver’s license? Yes: _____ No: ______ List all states in which
you have a driver’s license and license numbers: ______________________________
______________________________________________________________________
Has your driver’s license ever been suspended or revoked, or has your driving privilege
ever been restricted on placed on probation? Yes: _____ No: _____ If yes, explain
the circumstances:_______________________________________________________
______________________________________________________________________
Have you ever used technology, electronics, or a computer to commit a crime? Please
describe:
______________________________________________________________________
Have you ever used technology, electronics, or a computer for questionable moral or
ethical activity? Please describe: __________________________________________
______________________________________________________________________
I have read and answered all questions truthfully and to the best of my knowledge. I
understand that ANY deception or intentional withholding of information will result in the
immediate termination of the background process.
____________________________________________
Signature
_____________________
Date
Reviewed by: ________________________________
Date: ________________
Investigator’s Comments: ________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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