Explorer Personal History Statement - Santa Barbara County ...

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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