Personal history statement sworn personnel

FILLING OUT THE PERSONAL HISTORY STATEMENT WITH A COMPUTER

The downloaded Personal History Statement can be filled out on a computer with word processor. Follow these instructions when using a word processor to fill out the Personal History Statement:

1. Except for the fill-in areas, the Personal History Statement is “protected” (locked) to prevent the modification of the form. Do not remove the protection. Any unauthorized modification of the protected portions of the form will invalidate the entire document and it will not be accepted.

2. When typing in information, DO NOT USE ALL CAPITAL LETTERS.

3. Each information field will accept a limited number of characters. If a narrative field does not contain a sufficient number of characters for your complete response, end your response with the words, “Continued on attached page” and continue your response on an attached page.

4. Once the Personal History Statement is completely filled in, it is recommended that it be printed out and proof read. Once the final copy is printed, fill in by hand those areas that could not be filled in with the word processor, such as your initials, signature, and date at the bottom of some of the pages. Be aware that one particular waiver and release must be filled-in by a notary and signed by you in the notary’s presence.

5. Once you have completely filled out the Personal History Statement, print it out single-sided. Personal History Statements printed double-sided will not be accepted. You are encouraged to keep a copy for your records and submit the original.

REQUIRED DOCUMENTS

You are required to submit copies of those documents which apply to you and are listed on the form entitled "Required Documents." Note that there is a signature block on the "Required Documents" form. Sign this form and return it with the required documents that apply to you. Do not send original materials through the mail. Make a photocopy of the required documents and submit them, except when required to submit certified copies. If you are unable to gather all of the materials by the due date, submit what you have gathered along with a written explanation of what you have done in your attempt to obtain the remaining materials.

PRE‑EMPLOYMENT INVESTIGATION DISCOVERY WAIVER

Included in this package is a waiver wherein you sign to acknowledge and hold harmless the Sacramento County Sheriff's Department for any negative action resulting from the investigation being conducted upon you. In addition, you acknowledge by your signature that you may not examine, review or otherwise discover the contents of the investigation or related documents.

MOTOR VEHICLE FINANCIAL RESPONSIBILITY

Included in this package is the Motor Vehicle Financial Responsibility form required by state law which acknowledges your understanding that every licensed driver and owner of a motor vehicle must comply with the financial responsibility specified in Vehicle Code Section 16021. Please sign this form.

RELEASE AND WAIVER

Included in this package is the “Release and Waiver” which authorizes Sheriff's Department investigators to access your confidential records. Your signature authorizes that access. Please sign this form. This form must be notarized. Notary service is available at the Pre-Employment Investigation Unit free of charge. Please call in advance to ensure that a notary will be available.

PERSONAL DATA

Included in this package is a Personal Data form. Please ensure that all information typed into this form contains no errors. It will become the work sheet for the investigator. A single error such as a mistyped letter or number could result in an inaccurate pre‑employment investigation. A substantial error could cause you to not be considered for selection, as an appointment is contingent upon a completed investigation.

AUTHORIZATION FOR RELEASE OF MILITARY & MEDICAL INFORMATION

Included in this package is an “Authorization for Release of Military and Medical Information form”. This form is to be signed in the signature box indicated with a black “x”. DO NOT INCLUDE ANY OTHER INFORMATION.

FINGERPRINT INFORMATION FORM

Included in this package is a Fingerprint Information Form. Please fill out the necessary information on the corresponding lines where you see the arrow symbol. (DO NOT HAVE YOUR FINGERPRINTS TAKEN.)

CHANGES IN PERSONAL HISTORY STATEMENT

If at any time after you have submitted your Personal History Statement a change develops in your personal history, (i.e., address change, employment change, marital status, driving or arrest record, etc.) you are required to notify the Pre‑Employment Investigations Unit as soon as possible both verbally and in writing.

TURNING IN YOUR PERSONAL HISTORY STATEMENT

Your Personal History Statement must be received by 4:00 p.m. on the final filing date. It can either be submitted in person at the Pre-Employment Office at the Sheriff’s Pre-Employment Facility or by mailing it to:

Sacramento County Sheriff’s Department

Pre-Employment Investigations Unit

711 G Street

Sacramento, CA 95814
Mailing Address

P.O. Box 988

Sacramento, CA 95812-0988

The above requirements represent the beginning of the process. There are many other details that must be completed. It is our hope to keep this process moving in a timely manner. To do that, we need your cooperation. We intend to keep you advised by mail and will be unavailable to answer questions via the telephone.

Documents to be signed for your

Pre-Employment background investigation

The following series of documents require your careful review and your knowing and voluntary signature in order for your background investigation to begin. These are important documents, and oral explanations of their meaning and purpose may be misunderstood, incomplete or inadequate and are no substitute for your careful review and complete understanding.

• 
  Take as much time as you need to review each document carefully before signing.
  

• 
  If you do not understand a document or have questions about its purpose, meaning or impact, ask for any clarification you desire before signing.
  

• 
  If, after reviewing any or all of the documents and/or having any of your questions answered, you still feel that you do not understand the document(s) or wish to speak to an attorney of your choosing before signing any or all of them, please let Pre-Employment know, and time will be provided to you before proceeding further.
  

Printed Name of Applicant: _______________________________________________

Date Advisement Signed: _______________________________________________

REQUIRED DOCUMENTS

The Sacramento County Sheriff's Department requires that all applicants who desire to be considered for employment submit copies of the following listed documents:

A CERTIFIED COPY OF YOUR BIRTH CERTIFICATE OR AN ORIGINAL RECEIVED FROM THE ISSUING AGENCY (Available from the Registrar of Vital Statistics in the County of your birth, or from your State Department of Health.)

A COPY OF YOUR HIGH SCHOOL DIPLOMA OR REPORT OF G.E.D. TEST SCORES, OR A COPY OF CERTIFICATE OF HIGH SCHOOL PROFICIENCY OR HIGH SCHOOL EQUIVALENCY CERTIFICATE (Available from your high school or high school district office.)

OFFICIAL HIGH SCHOOL TRANSCRIPTS (Available from your high school records office or high school district office.)

OFFICIAL COLLEGE TRANSCRIPTS (Available from the Admissions and Records Office at each college or university you have attended.)

A COPY OF YOUR AUTOMOBILE INSURANCE POLICY, INSURANCE BINDER OR OTHER PROOF THAT YOU ARE COMPLYING WITH SECTIONS 16020 AND 16021 OF THE CALIFORNIA VEHICLE CODE (Available from your insurance agent. This document must show your name, name of carrier, policy number and expiration date.) OR PROVIDE A SIGNED STATEMENT WHICH INDICATES THAT YOU HAVE READ AND UNDERSTAND THE PROVISIONS OF VEHICLE CODE SECTIONS 16020 AND 16021

A COPY OF ALL COLLEGE DEGREES

A COPY OF ALL POLICE RELATED TRAINING CERTIFICATES ACQUIRED. THIS INCLUDES ANY CERTIFICATES OF PROFICIENCY OR COMPLETION OF TRAINING IN THIS AREA OF CALIFORNIA LAW ENFORCEMENT (EXCLUDING MILITARY). (Examples of such certificates are P.O.S.T. Basic, Intermediate and Advanced Certificates, Basic Academy Certificates, etc.)

A COPY OF ANY WRITTEN MATERIAL WHICH YOU HAVE IN YOUR POSSESSION WHICH REFLECTS YOUR PERFORMANCE OR CONDUCT DURING ANY EMPLOYMENT WITH A PUBLIC AGENCY, INCLUDING THE MILITARY (This includes such items as performance evaluation reports, letters of commendation, letters of reprimand, etc. We encourage you to attach your written explanation relative to letters of reprimand that you submit.)

A COPY OF YOUR MARRIAGE CERTIFICATE

A COPY OF DIVORCE PAPERS (Papers must indicate that a final divorce was granted.)

A COPY OF YOUR MILITARY SERVICE DISCHARGE - DD‑214 Long Form (Copy 4). (Note: DD-214 Short Form (Copy 1) is not acceptable for this purpose). Available online: http://www.archives.gov/veterans/military-service-records/

A COPY OF YOUR SELECTIVE SERVICE SYSTEM REGISTRATION ACKNOWLEDGMENT LETTER (Required of all males who were born on or after January 1, 1960, and who have no military experience.)

YOUR NATURALIZATION CERTIFICATE (If applicable. If you were born outside the United States to U.S. parent(s), provide either a Citizenship Certificate or other U.S. government document which states that you were born to U.S. citizens.)

A COPY OF YOUR CALIFORNIA DRIVER’S LICENSE

AN OFFICIAL COPY OF YOUR CALIFORNIA DRIVER’S LICENSE RECORD OBTAINED FROM DMV. (Note: Driving records downloaded and printed online are not acceptable for this purpose.) (Note: If you visit a DMV office to obtain your driving record, you are encouraged to make an appointment online.)

A COPY OF EACH POLICE ACCIDENT REPORT IN WHICH YOU WERE NAMED A DRIVER IN THE INCIDENT WITHIN THE PAST THREE YEARS

A COPY OF EACH POLICE REPORT IN WHICH YOU WERE ARRESTED OR NAMED AS A SUSPECT WHETHER OR NOT YOU WERE CHARGED OR CONVICTED (Available through either the County District Attorney’s Office or your attorney.)

A CERTIFIED COPY OF ANY CIVIL JUDGMENT MADE AGAINST YOU WITHIN THE PAST SEVEN YEARS

______________________________________________ ____________________________

SIGNED DATE

______________________________________________

NAME (Please print)

PRE-EMPLOYMENT INVESTIGATION DISCOVERY WAIVER

I fully recognize that individuals must clearly demonstrate their personal, medical, physical and psychological fitness to serve in a position of trust within the Sacramento County Sheriff's Department. I further recognize that this employing agency has a legal as well as a moral obligation to make every reasonable effort to insure that persons employed by them conform to the very highest standards.

To that end, I recognize that this law enforcement agency will conduct an intensive investigation into my personal, medical and psychological fitness, and that such an investigation will include contacting persons and/or organizations that may have information relating to my fitness. I further understand that those persons and/or organizations may feel inhibited, intimidated or otherwise reticent about furnishing legitimate information concerning me if the confidentiality of their information cannot be guaranteed on a permanent basis.

Therefore, I release and hold harmless the County of Sacramento, its Sheriff's Department, officers, agents or assigns, now and in the future, from any claim or damages in law or in equity on behalf of myself, my heirs and assigns, for their refusal to make available any and all of the information contained in this pre‑employment personal, medical and/or psychological history investigation, including, but not limited to, the identity(ies) of any person(s) and/or organization(s) which may have supplied information in the course of this investigation, as well as the substance of any information supplied. I hereby waive my right, now and in the future, to examine, review or otherwise discover the contents of this investigation and all related documents thereto.

Dated this _________day of _______________________, _____________ in the County of Sacramento, State of California

______________________________________

Signature of Person Giving Consent

__________________________________

Printed Name

MOTOR VEHICLE FINANCIAL RESPONSIBILITY

CALIFORNIA VEHICLE CODE SECTION 16020:

"Every driver of, and owner of, a motor vehicle shall, at all times, maintain in force one of the forms of financial responsibility specified in Section 16021."

"Financial responsibility of the driver or owner is established if the driver or owner of vehicle involved in an accident described in Section 16000 is:

1. 
   A self‑insurer under the provisions of this division.
   

2. 
   An insured or obligee under a form of insurance or bond which complies with the requirements of this division and which covers the driver for the vehicle involved in the accident.
   

3. 
   The United States of America, this state, any municipality or subdivision thereof, or the lawful agent thereof.
   

4. 
   A depositor in compliance with subdivision (a) of Section 16054.2.
   

5. 
   In compliance with the requirements authorized by the department by any other manner which effectuates the purposes of this chapter."
   

________________________________________ ___________________

SIGNED DATE

________________________________________

NAME (Please print)

PRE-EMPLOYMENT RELEASE AND WAIVER

I hereby authorize any Sheriff’s Officer or other authorized representative of the Sacramento County Sheriff’s Department bearing this release or a copy thereof to obtain information contained in any file, computer bank, or other compilation system relating to current employment, former employment, background investigation, credit, educational, military service, or criminal history information matters. This waiver extends to any and all information possessed by any educational institution, current or former employers, repository of military service records, and any and all businesses which retain credit history information. It also extends to any and all information possessed by any local, state, or federal law enforcement agency which retains criminal history information and/or background investigation information. It extends also to any and all information compiled in the internal affairs or disciplinary records of any law enforcement agency or repository of military service records.

I hereby direct you to release this information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for the official use of the Sacramento County Sheriff’s Department.

Consent is granted for the Sacramento County Sheriff’s Department to furnish the information described above to third parties in the course of fulfilling its official responsibilities.

I hereby release you, as the custodian of such records, and any school, college, university or other educational institution, credit bureau, lending institution, consumer reporting agency, retail business establishment, current employer, former employer of any capacity, law enforcement agency, including its officers, employees, or related personnel both individually and collectively, from any and all liability for damage of whatever kind, which may at any time result to me, my heirs, family and associates resulting from the authorized release of information or attempted release of such information, pursuant to the terms of this release and waiver.

State of ______________________________________}, County of ______________________________________}

On_____________________ before me, _______________________________, Notary Public, personally appeared

_____________________________________________________, who proved to me on the basis of satisfactory evidence to be the same person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal.

Affiant______ Produced ID ______ ________________________________________

Signature
____________________ ________________________________________

Type of ID Notary’s Signature

EXPIRATION IS ONE YEAR OF THE DATE INDICATED ABOVE

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

I hereby authorize any Sheriff’s Deputy or other authorized representative of the Sacramento County Sheriff’s Department bearing this release or copy thereof to obtain information contained in any file, computer bank, or other compilation system relating to my current employment, former employment, credit, educational, or criminal history information matters. Information obtained may include information on a candidate’s character, general reputation, personal characteristics, and mode of living. This waiver extends to any and all information possessed by any education institution, current employers, and any and all businesses, which retain credit history information. It also extends to any and all information possessed by any local, state, or federal law enforcement agency, which retains criminal and driving history information. It also extends to any and all information complied in internal affairs or disciplinary records of any law enforcement agency wherein I have been accused of misconduct, whether sustained or not.

According to the Investigative Consumer Reporting Agencies Act (ICRAA), I acknowledge that I am entitled to a copy of public records obtained during the course of the pre-employment investigation conducted by authorized representatives from the Sacramento County Sheriff’s Department. I also acknowledge that public records, as used in this disclosure form, do not include responses by personal references, employment verifications.

No, I do not want a copy of all public records obtained in the course of my background investigation.

Yes, I would like a copy of all public records obtained in the course of my background investigation.

Dated this ______day of ________________, ___________ in the County of _________________________,

State of ____________________

______________________________________

Signature of Person Giving Consent

____________________________________

Printed Name

EMPLOYMENT DEVELOPMENT DEPARTMENT

AUTHORIZATION FOR RELEASE OF RECORDS

I, , authorize the Employment Development

Department to release a copy of my records pertaining to:

• 
  Unemployment records
  
• 
  Employment History
  

Sacramento County Sheriff’s Department

Pre-Employment Investigations Unit

P.O. Box 988

Sacramento, CA 95812-0988

This Authorization shall remain in effect for one (1) year from date of signature. A copy of this Authorization shall be valid as the original.

Date: Signature:

Social Security Number*

*Providing your social security number on this form is voluntary and if you provide your social security number,

it will be used solely for the purpose of locating the requested records. If you choose not to provide your social security number, the Employment Development Department may be unable to locate any or all requested

records due to the Employment Development Department’s use of social security numbers for record identification and filing purposes. Privacy Act of 1974 Section 7(b) (Public Law 93-579).

F.P. NUMBER

DATE

CII#_________________________

FBI#_________________________

NAME: LAST FIRST MIDDLE                   								MAIDEN OR ALIAS      
HOME ADDRESS STREET & APPT# CITY STATE ZIP                      
HOME PHONE  (     )    -    	RACE      			SEX      			HEIGHT  -  				WEIGHT    
COLOR OF HAIR       	COLOR OF EYES      					AGE   				DATE OF BIRTH (M/D/YYYY)      
PLACE OF BIRTH: CITY/STATE       		CITIZEN (COUNTRY)      				ANY SCARS, MARKS, TATTOOS, ETC      .
OCCUPATION       			DRIVER'S LICENSE NUMBER – STATE      						SOCIAL SECURITY NUMBER    -    -    
WHERE EMPLOYED (NAME OF BUSINESS)       									BUSINESS PHONE (   )    -    
BUSINESS ADDRESS CITY STATE ZIP                      
IN CASE OF EMERGENCY NOTIFY: NAME RELATIONSHIP             
ADDRESS: NUMBER STREET CITY STATE ZIP                      
POSITION APPLYING FOR       
HAVE YOU EVER BEEN ARRESTED FOR ANY OFFENSE?  NO YES IF YES, EXPLAIN BELOW					HAVE YOU EVER BEEN CONVICTED OF ANY OFFENSE?  NO YES IF YES, EXPLAIN BELOW
     					     
     					     
     					     
I UNDERSTAND THAT SACRAMENTO COUNTY CODE 9.20.010 MAKES IT A MISDEMEANOR FOR ANY PERSON TO MAKE FALSE OR FRAUDULENT STATEMENTS, OR ANY FALSE OR MISLEADING WRITING OR DOCUMENT IN ANY MATTER OR PROCEEDING WITHIN THE JURISDICTION OF ANY DEPARTMENT OR AGENCY OF THE COUNTY OF SACRAMENTO.
SIGNATURE OF APPLICANT 

SACRAMENTO COUNTY SHERIFF’S DEPARTMENT

I understand that as an applicant for a position as a Peace Officer, I must be in good physical condition, free of any physical ailments or conditions that may prevent me from performing all the duties of a Peace Officer. These duties are mandated by the California Penal Code, Sections 830.1, 830.6, 832.6 and the Commission on Police Standards and Training (P.O.S.T.).

I understand that before being considered for appointment as a Peace Officer, I must be examined by a physician as authorized by the County of Sacramento, and found to be free of any physical ailment which might adversely affect my ability as a peace officer.

I also understand that it may be necessary for the Sacramento County Sheriff’s Department, its officers, agents and assigns to review any and all of my medical records, as to further evaluate my physical condition. I understand that this authorization releasing my medical records to the Sacramento Sheriff’s Department, as provided in this paragraph, will expire one year after the date signed.

I further understand that the results of my physical examination and/or the contents of my medical records will be reviewed by personnel of the Sacramento County Sheriff’s Department for determination of the suitability of my physical condition for peace officer duties. I understand that the results of my physical examination and/or the contents of my medical records may be relevant to mental health professionals conducting pre-employment psychological evaluations.

Therefore, I waive any privilege of confidentiality of “physician-patient relationship,” to the extent that the results of the examination hereinbefore described and any other medical records as may otherwise exist, may now or at any time within one year hereafter be released to the Sacramento County Sheriff’s Department, its officer, agents and assigns, for the purpose of assessing my physical suitability for peace officer duties and specifically authorize such physicians, hospitals, their agents or employees to release such records. I also waive any privilege of confidentiality of “physician-patient relationship,” to the extent that the results of the examination hereinbefore described and any other medical records as may otherwise exist, may now or at any time within one year hereafter be discussed with mental health professionals conducting pre-employment psychological evaluations for the purpose of assisting the mental health professionals in determining the suitability of my mental or emotional condition for peace officer duties.

Dated this _____day of _______________, _________ in the County of _______________________,

State of ___________________________

______________________________________

Signature of Person Giving Consent

__________________________________

Printed Name

SACRAMENTO COUNTY SHERIFF’S DEPARTMENT

I understand that before any person in California may be declared by law to be a peace officer, he or she must be found, after examination by a qualified physician or psychologist, to be free from any emotional or mental condition which might adversely affect the exercise of peace officer powers.

I understand that before being considered for appointment as a peace officer with the Sacramento County Sheriff’s Department, I must be examined by a physician or qualified psychologist, and found to be free of any emotional or mental condition which might adversely affect my ability as a peace officer. Such examination or examination will include, but not necessarily be limited to, the Minnesota Multi phasic Personality Inventory (MMPI), The California Psychological Inventory Police Effectiveness Index, and no less than one clinical interview session with the physician or qualified psychologist.

I further understand that the results of my physical examination or examinations will be reviewed by personnel of the Sacramento County Sheriff’s Department for determination of the suitability of my mental or emotional condition for peace officer duties. I understand that the results of my psychological examination and/or the contents of my psychological records may be relevant to health professionals conducting pre-employment medical evaluations.

Therefore, I waive any privilege of confidentiality of “physician-patient relationship,” or “psychotherapist-patient relationship,” to the extent that the results of the examination hereinbefore described and any other psychological records as may otherwise exist may now or at any future time be released to the Sacramento County Sheriff’s Department, its officers, agents and assigns, for the purpose of assessing my emotional and mental suitability for the peace officer duties and authorize such physicians, psychologists, their agents or employees to release such records. I also waive any privilege of confidentiality of “psychotherapist-patient relationship,” to the extent that the results of the examination hereinbefore described and any other psychological records as may otherwise exist, may now or at any time within one year hereafter be discussed with medical professionals conducting pre-employment medical evaluations for the purpose of assisting the medical professionals in determining the suitability of my medical condition for peace officer duties.

Dated this _____day of _______________, _________ in the County of _______________________,

State of ___________________________

______________________________________

Signature of Person Giving Consent

__________________________________

Printed Name

Department of Transportation (DOT)

Supplemental Questionnaire
1. Have you previously held a DOT position? ___Yes ___No
2. Do you currently possess a valid Class A or B Driver’s License? ___Yes ___No
3. Have you previously possessed a Class A or B Driver’s License? ___Yes ___No
4. In the past two years, have you ever been denied employment due to

a positive drug test? ___Yes ___No

5. In the past two years, have you ever been denied employment due to

a positive alcohol test? ___Yes ___No

If so, list the date(s) of occurrence, employer(s) name and any further details:

6. 
   In the past two years have you ever refused to take a required drug
   

6. 
   In the past two (2) years have you ever tested positive for a controlled
   

6. 
   In the past two (2) years have you ever had an alcohol test with a Breath
   

6. 
   If you answered yes to questions 4, 5, 6, or 7, did you complete the
   

_____________________________________

Candidate’s Signature

_____________________________________ ______________________

Candidate’s Name Printed Date

SECTION 1: PERSONAL

1. your full name last      

1. your full name first      

1. your full name 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

home      

BUSINESS      

7. If you were born outside of the United States, are you a U.S. citizen? Yes No If no, are you a resident alien who is eligible and has applied for U.S. citizenship? Yes No

8. birth place (city / county / state / country)      

9. BIRTH DATE      

10. social security number     –    –     

11. Driver’s license

12. physical description

No.      

state   

exp      

HEIGHT      

wEIGHT    

HAIR COLOR      

EYE COLOR      

SECTION 2: RELATIVES AND REFERENCES

13. IMMEDIATE FAMILY  Provide all applicable information in the spaces below.  Mark “N/A” if a category is not applicable or if the individual is deceased.  If more space is needed, continue your response on page 26.

N/A

A. Father

NAME      

HOME ADDRESS (number / street / apt) CITY STATE ZIP                     

HOME PHONE (     )      

work ADDRESS (number / street / apt) CITY STATE ZIP                     

work PHONE (     )      

CELL PHONE (     )      

EMAIL      

N/A

B. Step-father

NAME      

HOME ADDRESS (number / street / apt) CITY STATE ZIP                     

HOME PHONE (     )      

work ADDRESS (number / street / apt) CITY STATE ZIP                     

work PHONE (     )      

CELL PHONE (     )      

EMAIL      

N/A

C. Mother

NAME      

HOME ADDRESS (number / street / apt) CITY STATE ZIP                     

HOME PHONE (     )                     

work ADDRESS (number / street / apt) CITY STATE ZIP                     

work PHONE (     )      

CELL PHONE (     )      

EMAIL      

SECTION 2: RELATIVES AND REFERENCES continued
13. IMMEDIATE FAMILY continued
N/A	D. Step-mother
NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      	EMAIL      
N/A	E. Spouse / Registered Domestic Partner
NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      	EMAIL      
		years of marriage   	Is there, or has there been, a restraining or stay-away order in effect for this individual? Yes No
N/A	F. Father-in-law
NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      	EMAIL      
N/A	G. Mother-in-law
NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      	EMAIL      
N/A	H. Former Spouse(s) / Former Registered Domestic Partner(s)
1) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      	EMAIL      
		year of dissolution      	Is there, or has there been, a restraining or stay-away order in effect for this individual? Yes No
2) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      	EMAIL      
		year of dissolution      	Is there, or has there been, a restraining or stay-away order in effect for this individual? Yes No

SECTION 2: RELATIVES AND REFERENCES continued
13. IMMEDIATE FAMILY continued
N/A	I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc.
1) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
M F under age 18		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
2) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
M F under age 18		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (          		CELL PHONE (     )      		EMAIL      
3) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
M F under age 18		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
4) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
M F under age 18		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
5) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
M F under age 18		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
6) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
M F under age 18		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work 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.
1) NAME      					custodial parent or guardian (if other than you)      
M F			child’s age   		ADDRESS (number / street / apt) CITY STATE ZIP                     
					contact number (     )      		EMAIL      
2) NAME      					custodial parent or guardian (if other than you)      
M F			child’s age   		ADDRESS (number / street / apt) CITY STATE ZIP                     
					contact number (     )      		EMAIL      

SECTION 2: RELATIVES AND REFERENCES continued
13. IMMEDIATE FAMILY (Section J. Children) continued
3) NAME      					custodial parent or guardian (if other than you)      
M F			child’s age   		ADDRESS (number / street / apt) CITY STATE ZIP                     
					contact number (     )      		EMAIL      
4) NAME      					custodial parent or guardian (if other than you)      
M F			child’s age   		ADDRESS (number / street / apt) CITY STATE ZIP                     
					contact number (     )      		EMAIL      
5) NAME      					custodial parent or guardian (if other than you)      
M F			child’s age   		ADDRESS (number / street / apt) CITY STATE ZIP                     
					contact number (     )      		EMAIL      
6) NAME      					custodial parent or guardian (if other than you)      
M F			child’s age   		ADDRESS (number / street / apt) CITY STATE ZIP                     
					contact number (     )      		EMAIL      
14. references List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.
A) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
	how do you know this person? (for example: friend, teacher, family friend, co- worker)      							How long have you known this person?      
b) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )                     		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
	how do you know this person? (for example: friend, teacher, family friend, co- worker)      							How long have you known this person?      
c) NAME      				home ADDRESS (number / street / apt) CITY STATE ZIP                     
		HOME PHONE (     )      		work ADDRESS (number / street / apt) CITY STATE ZIP                     
		work PHONE (     )      		CELL PHONE (     )      		EMAIL      
	how do you know this person? (for example: friend, teacher, family friend, co- worker)      							How long have you known this person?