Statement of Personalhistory

DATE:

CLACKAMASCOUNTYCOMMUNICATIONSDEPARTMENT

Statement of PersonalHistory

STOP!Gatheryourinformationbeforecompletingthisform!

Theinformation furnished on this application form is confidential and is to beutilized forthepurposes of enablingthe ClackamasCountyDepartmentofCommunicationsto determine the applicant’squalifications.

All questions must beanswered completely, accuratelyandcandidly. All statements inthis questionnairearesubject toverification.

You increaseyourchances ofgainingemployment at theClackamas CountyCommunications Department byansweringall questions completely,accuratelyandcandidly both on this form and with your Background Investigator.Ifyou havebeen terminated from employment, haveacriminal record orotherunfavorablematter(s), those matters alonemaynot keepyou from being accepted.

Youranswersonthisformwillnot automatically disqualify youfromemployment, pleaseinclude allinformationrequested; however, theintentional omission, falsification or failuretodiscloseanymatter willbea basis to reject your application.

Pleasetypeorprintinink: Besuretoincludethezipcodesofeveryaddressentered.

What Position Are You Applying For (Circle One Below):
Dispatcher Trainee | Dispatcher 1 Lateral | Other
Name:
Last First Middle / Social Security Number:
DPSST or Other Police Certification # (which state): / Date of Birth: / Place of Birth:
Residence Address:
Mailing Address:
Height: / Weight: / Eye Color: / Hair Color: / Driver’s License Number & State:
Email Address: / Home Phone Number: / Cell Phone Number:

Statement of Personal History | Application for Clackamas 911

INSTRUCTIONS

Pleasereadtheseinstructions carefully.Yourability to followinstructionsaccurately andina timely fashionis part ofthe backgroundprocess.

COMPLETING THE SPH FORM

Here are some additional instructions for completing this form:

Do not change or edit this form.
Ifspaceprovided for an answer is inadequate, addcommentsto thesupplemental sheets in theback ofthis formand identifythe information bysection and block number.
Ifan item does not apply,enter“DNA.”
Ifa question is unknown, enter “UNK.”
Ifyou areprintingthis form out, do notput this application or additional paperwork in abinder.
Do not include letters of reference or additional paperwork.
Do notsignanddateSection12 ofthedocument. Ifyou areselected to proceed to thebackground process,you will sign this document in thepresenceofthebackground investigator.
Ifyou changeyouraddress ortelephonenumberafter you have submitted your form,notify Merry Broughal via email at immediately.

SUBMITTING THE SPH FORM

Formsmayonlybesubmittedduringtheopenrecruitmentperiodinoneofthefollowingtwoways:

ByEmail: Saveandattachthisformtoane-mailandsenditto

In-Person:PrintoutthecompletedformanddropitoffatC-COMat2200KaenRoad in OregonCity. This must be done only on Monday-Thursday during the hours of 7:00 a.m. and 5:00 p.m.

YoumayexpecttoreceivecontactfromMerry Broughalwithin5businessdaysofthereceiptofyourSPH. Ifyouhavenotheardbackwithin5businessdays,.

DO NOT submit or turn in this SPHform if it isnotcomplete.

SECTION 1: PERSONAL INFORMATION

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

A. List any other name which you have used or by which you have been known (include all aliases, nicknames, maiden names, and married names used). Explain why, where and when it was used.
1. / 2.
3. / 4.
B. Are you a U.S. Citizen? / YES or NO
If Naturalized, include the date, place and Court of Naturalization Name here:
C. Can you perform the essential functions of this position as outlined in the job announcement, with or without reasonable accommodations? / WITH or WITHOUT ACCOMMODATIONS
If WITH, please describe:
D. Have you ever been named as a suspect, charged or arrested for a crime? / YES or NO
If YES, please describe:
E. Is there anything in your life that may reflect upon your suitability to perform the duties of the position for which you are applying? / YES or NO
If YES, please describe:
F. Haveyoueverbeennamedinapolicereportforanything? / YES or NO
If YES, please listeverycontact youhaveever hadwithapoliceofficer,campussecurityoranylawenforcementofficer.
G. Haveyoueverbeennamedinorbeenapartytoa restrainingorderorstalkingorder? / YES or NO
If YES, please describe:
H. Haveyoueverbeenadefendant,apetitionerorawitnessina lawsuit? / YES or NO
If YES, please describe:
I. Haveyoueverusedany Schedule 1 or II controlled substance(includingmarijuana) outside of a medical prescription? / YES or NO
If YES, please describe:

SECTION 2: MOTOR VEHICLE RECORD

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

A. Doyouhavealicensetooperateamotorvehicle? / YES or NO
If YES, which state?
B. Is your driver’s license currently valid? / YES or NO
If NO, describe your reliable transportation plan
C. Hasyourdriver’slicenseeverbeensuspendedorrevoked? / YES or NO
If YES, please describe:
D. Haveyoueverbeenconvictedof orpaidfinesforanytrafficviolations,exceptparking ordinances / YES or NO
If YES, please describe:
E. Haveyoueverfailedto appearforanycourtappearanceeithertrafficorcriminalrelated? / YES or NO
If YES, please describe:

SECTION 3: WEAPON PERMIT

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

A. Haveyoueverappliedforaconcealedweaponpermit? / YES or NO
B. Didyoureceivetheconcealedweaponpermit? / YES or NO
If YES, note the law enforcement agency, permit
If NO, please describe why not:
If YES, Law Enforcement Agency: / Permit #
Law Enforcement Agency Address: / Date of CCW Issue:
C. Have you ever had your permit revoked? / YES or NO
If YES, please describe:
D. Can you legally possess a firearm? / YES or NO
If NO, please describe:

SECTION 4: RELATIONSHIP STATUS

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

Current Relationship Status / Single | Married | Divorced | Domestic Partner
(Remove answers that don’t apply)
Full Name of Current Partner: / DOB of Partner: / Date of Marriage:
Partner Maiden Name: / Employer’s Name, Address & Phone Number:
Date of Divorce: / Court for Divorce (with address)
For more than 4 marriages, please add the following information on supplemental pages.
Full Name of Partner: / DOB of Partner: / Date of Marriage:
Partner Maiden Name: / Employer’s Name, Address & Phone Number:
Date of Divorce: / Court for Divorce (with address)
Full Name of Partner: / DOB of Partner: / Date of Marriage:
Partner Maiden Name: / Employer’s Name, Address & Phone Number:
Date of Divorce: / Court for Divorce (with address)
Full Name of Partner: / DOB of Partner: / Date of Marriage:
Partner Maiden Name: / Employer’s Name, Address & Phone Number:
Date of Divorce: / Court for Divorce (with address)

SECTION 5: RELATIVES

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

List the full names of APPLICANT’S parents or guardians, siblings as indicated

Parent/Guardian Name: / Date of Birth
Parent/Guardian Address: / Phone Number
Other Parent/Guardian Name: / Date of Birth
Other Parent/Guardian Address: / Phone Number
Sibling Name / Date of Birth
Address / Phone Number
Sibling Name / Date of Birth
Address / Phone Number
Sibling Name / Date of Birth
Address / Phone Number

List the full names of SPOUSE/PARTNER’S parents or guardians, siblings as indicated

List the full names of all children and persons with who you currently reside

Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
Name & Relationship: / Date of Birth:
D. Hasanyrelativeofyours,oryourcurrentorformerspouse/significantother,oranyonepreviouslyor currentlylivingwith youoranyoneyouarepreviouslyorcurrentlyassociatedwitheverbeenconvictedof afelonyunderthe lawsof anystateorfederallaw?
YES or NO
If YES, list all on the supplemental page

SECTION 6: RESIDENCES

Listbelowallresidencessince18yearsofage.
Listpresentaddressfirst.Includeallmilitarystations.Use supplementalpageifnecessary.
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)
Full Address:
County: / Dates: From - To / OWNED or RENTED
(delete incorrect answer)

SECTION 7: EDUCATION

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

A. Are you a high school graduate or do you have a GED? / YES or NO
B. What is the highest grade you have completed?
Delete all non-applicable answers / High School
9 10 11 12 / Bachelor
13 14 15 16 / Masters
17 18 / Doctoral
19 20
C. List all civilian and military schools, starting from the most current:
Name/Address of School / Dates of Attendance / Graduated? / Major / Degree Type / Credit Hours
D. List all licenses and certifications:
1. / 2.
3. / 4.
5. / 6.
E. Have you ever been denied for a license for which you applied? YES or NO (if yes, explain on supplemental pages)
F. Have you ever had your professional license suspended, revoked, censured or placed on probation for any reason? YES or NO
(if yes, list the reasons & dates on the supplemental pages)

SECTION 8: MILITARY

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

A. Have you ever served in the armed forces of United States? / YES or NO
B. Branch of service / Date of Entry / Date of Discharge / Type of Discharge / Rank Attained
C. Job Performed:
D. Period of Military Obligation Remaining:
E. Are you in the National Guard or Reserve? YES or NO (if yes, explain fully)
F. Are you registered with the Selective Service? / State Registered?
G. Whileinthemilitary,wereyoueverarrestedforanyoffense,adefendantinanytrial,ordidyou receiveanydisciplinaryactionincludingNon-JudicialPunishment?
Ifyes,givedate,place,lawenforcementagencyortype,court,orcourtmartialandactiontakenon
asupplementalpage.
E. While in the military, were you ever listed as AWOL or on unauthorized leave?
Ifyes,please explain.

SECTION 9: EMPLOYMENT

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

A. Haveyoueverbeeninvolvedin anyincidentthatresultedin employmentdisciplineactionof any kindincludingmaterialreflectingcaution,consultation,admonishment,warning,writtenororal reprimand? / YES or NO
(if yes, please explain)
B. Haveyoueverbeendischarged,rejected,orhaveyouresignedunderpressureorunfavorable circumstancesorundermutualseparationfrom anyemployment? / YES or NO
(if yes, please explain)
C. Would any problems result if your present employer were contacted during the course of this background investigation? / YES or NO
(if yes, please explain)
SPECIAL INSTRUCTIONS FOR THIS SECTION:

Listbeloweveryperiodofemploymentandemployersince age18orforthelast15years, whicheverislonger;

Beginwithpresentemployment;
Includeparttimeandvolunteer jobs;
Listdatesofnon-employmentwithexplanationon supplementalform; and
USEASUPPLEMENTALPAGEIFNECESSARY

Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving
Dates of Employment / Employer Name / Job Title
Phone Number / Employer Address / Supervisor Name & Phone Number
Reason for Leaving

SECTION 10: REFERENCES

SPECIAL INSTRUCTIONS FOR THIS SECTION:

Listseven(7)personsnotrelatedtoyou, yourspouse orsignificantotherwhoknowyouwellthatwemaycontact.
Preferablylistresidentsof Oregon.
Donotincludecurrentemployersor co-workers.
Failureto furnishallof the informationbelowwillpreventprocessingyourapplication.

Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)
Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)
Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)
Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)
Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)
Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)
Name / Email Address / Phone Number
Address / How Long Have You Known This Person?
Occupation / Other Phone Numbers (Cell/Work)

SECTION 11: CONCLUSION

For YES or NO Questions, delete the WRONG ANSWER so that the CORRECT ANSWER remains in the cell.

If you need to supply any additional information, please reference the Section and Question Number on your Supplemental Page(s).

A. Doyouhavean activeapplicationonfileorhave youeverappliedwithanyotherrelatedagency? / YES or NO
If YES, please list the agency, address, date of application and status if known
Agency Name / Agency Address / Date of Application / Status
Agency Name / Agency Address / Date of Application / Status
Agency Name / Agency Address / Date of Application / Status
Agency Name / Agency Address / Date of Application / Status
B. Are you willing to take an oath to support the Constitution of the United States and the Constitution of the State of Oregon? YES or NO

SECTION 12: EXPERIENCE | TRAINING | SPECIAL QUALIFICATIONS

Summarizeexperience,trainingandspecialqualificationswhich,inyouropinion,establishyourfitnessforservicein the Department.Includeexperiencewithrelatedoccupation,awardsorcommunityservice.

SECTION 13: SUPPLEMENTAL INFORMATION

Use this page(s) to fully explain all supplemental information.
LIST THE SECTION NUMBER AND LETTER OF THE QUESTION BEING REFERENCED.

**Do NOTsign unlessyou are in thepresenceof thebackgroundinvestigator**

Iherebycertifythatallstatementsmadein thisStatement of Personal History (SPH) application,or appendedto, aretrueand correct tothebest ofmyknowledge. Iam awarethatwithholding pertinentinformation or includinginformation, found to begrosslyinaccurate,will becauseforrefusingfurther consideration of myapplication. Iunderstand thisisnotto beconsideredasan indication ofprobableappointmentnoran obligation upon thedepartmentto makean appointment,but a part of theselectionprocessonly. Iacknowledgethat Iamawarethe resultsof theinvestigation areconfidential. Theresultsof thisinvestigation areforthe use oftheClackamasCountyCommunicationsDepartment only and will not be disclosedtomyself or anyotherperson,except asrequiredbylaw.

Applicant’s Signature: ______Date: ______

Background Investigator’s Initials: ______

**Do NOTsign unlessyou are in thepresenceof thebackgroundinvestigator**

Statement of Personal History | Application for Clackamas 911