Personal History Statement and Background Check Authorization Instructions

Provide any additional information or details that are not covered elsewhere on the form.

Provide any additional information or details that are not covered elsewhere on the form.

Please enter the applicant's full name, including last, first, and middle names.

Please enter any maiden names or other names previously used by the applicant, including last, first, and middle names. Write 'None' if no other names have been used.

Provide any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Continue providing any additional details or explanations pertaining to the authorization or certification section on this line. Fill only if 'Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?' is 'Yes'.

Provide a detailed explanation of any criminal offenses or convictions other than minor traffic violations. Fill only if 'Check Box1' is 'Yes'.

Please enter your complete current address, including street, apartment number, city, county, state, and zip code.

Please provide your driver's license number.

Please enter the state that issued your driver's license.

Please provide the expiration date of your driver's license.

Please provide the complete street address, apartment number, city, county, state, and zip code for this previous address.

Please provide the start and end dates for the period you resided at this previous address.

Please provide the complete fourth previous address, including street, apartment number, city, county, state, and zip code.

Please provide the start and end dates for which you resided at the fourth previous address.

Enter your home telephone number, including the area code.

Enter the applicant's date of birth.

Enter the applicant's current age.

Enter the county and state where the applicant was born.

Enter the applicant's country of citizenship.

Enter the applicant's height in feet and inches.

Enter the applicant's weight in pounds.

Enter the applicant's hair color.

Enter the applicant's eye color.

Enter the applicant's skin tone.

Enter the applicant's race.

Please provide the complete street address, including apartment number, city, county, state, and zip code for the second previous address.

Please provide the start and end dates of residency at the second previous address.

Please provide your Social Security Number.

Please re-enter your Social Security Number for verification.

Please provide the street address, apartment number, city, county, state, and zip code for your third previous address.

Please provide the start and end dates of residence for your third previous address.