Draft POLICE DEPARTMENT - New York City

1 DraftPOLICE DEPARTMENTAPD-5 city OF NEW YORKP ersonal History of: ,Applicant for appointment as: POLICE OfficerExam Number:List Number:Social Security No.:APPLICANT PROCESSING DIVISIONINSTRUCTIONS FOR THE ONLINE PERSONAL HISTORY QUESTIONNAIRE(APD-5 BOOKLET)The following is a list of instructions, information and documents that an eligible candidate forthe position of new york city POLICE Officer should have available to them prior to registeringand obtaining a password on the website to complete the online Personal HistoryQuestionnaire (APD-5 Booklet). The documents listed will be presented to your investigators atthe first initial interview when the investigation process Certificate - an official copy with a raised seal.

2 If no record of your birth is on file at theDepartment of Health or the Bureau of Vital Statistics of the State in which you were born,obtain a statement from the agency attesting to the Change obtain records of name change, if Certificate foreign born candidates. POLICE Officers must be Citizens atthe time of School Diplomas, High School Equivalency Diploma, or Armed Forces GEDC ertificate (the record of scores you obtained in the individual tests must be presented),Diplomas and Degrees from Colleges attended. Official Transcripts from all colleges youattended either part time or full time must be Certificate if married.

3 Certificate must be issued by a governmental agency. BirthCertificates of Children if Domestic Partnership or Civil Union - Certificate must be issued by agovernmental - records of divorce, annulment or legal separation, if of 25 Social Security Card - A Detail Earnings Report for a fee obtained from the Social SecurityAdministration for the employments you had since leaving high school is Vehicle Driver s License Certificate of Motor Vehicle Registration for any vehicleowned by you or your spouse. A DMV abstract from the DEPARTMENT of Motor Vehicles wouldbe helpful for summons Service Registration - and classification cards (male candidates only) to register,obtain or check on a registration via the internet go to Discharge or Separation papers for all military service (DD214 member 4 page).

4 W-2 Forms - Withholding tax certificates and copies of income tax returns for the past fiveyears (especially for self employment).Employments all dates of employments and contact information since leaving high school(Detailed Social Security Earnings Report).Unemployment all dates of unemployment since leaving high school with a notarized letterobtained from persons other than yourself stating that they financially supported Benefits Worker s Compensation provide all Cards all labor union, fraternal or social organizations to which you Judgments Garnishees provide all of Residence two (2) proofs of residence (rent stub, utility bill, etc.)

5 For currentaddress).Court Dispositions transcripts and/or dispositions from the Court Clerk of the court of trialfor any arrest in which you were the defendant. Proof of payment for any summonses youreceived (other than traffic summonses).Licenses any licenses held by you (both past and present) from a government agency(pistol, rifle, hack, liquor, etc.).DISCLOSURE NOTICEThis is an acknowledgement that the information provided above has been read, reviewed andunderstood by the candidate completing the Personal History Questionnaire. The items anddocuments listed above will ensure that you have access to authentic and accurate informationfor the processing of your investigation.

6 Failure to truthfully disclose authentic, accurateinformation and/or presenting false documentation can result in your disqualification from theinvestigation process of becoming a new york city POLICE Disagree2 of 25I. Personal DataLast Name:First Name:Middle Initial:SSN:a. Have you ever had a legal name change? nullIf so:From: N/ATo : N/AReason: N/Ab. List below any other name, alias, or nickname by which you have ever been known(including maiden name, if you are a married female) with reason for such use:N/Ac. Do you have any tattoos, brands, body piercings, or other body art? nullIf yes, include the location and complete description, including symbolized meaning,and reason for getting same: N/A2.

7 Sex: null3. Date of Birth: N/A4. Birth Certificate:Certificate Number: N/ACity or Town: N/ACounty Of: N/AState: NA5. Citizenship: Citizen of the nulla. What country were you born in? Not Availableb. If not born in the , date entered : N/Ac. Are you a naturalized citizen of the so, list below:Naturalization Certificate No.: N/ADate: N/ACourt: N/ACity: N/AState: NAd. Do you have a dual citizenship with another country? nullIf yes, what country? Not AvailableWhen was it obtained? N/AHow was it obtained? N/A6. Do you have a Resident Alien Card? null3 of 25If yes, how was it obtained? (Lottery, etc.)N/AExpiration Date: N/AAlien Registration No.

8 : N/A7. Do you now have, or have you ever had a US passport? nullIf yes, enter information below:Passport No.: N/ADate Issued: N/AExpiration Date: N/Aa. Have you ever reported a passport lost or stolen? nullIf yes, describe the circumstances of the loss to include the date, location, and policereport Do you now have or have you ever had a foreign passport? nullIf yes:Date Issued: N/ADate of Surrender/Expiration: N/AIssuing Country: Not Availablec. Have you ever applied for a travel visa to travel to or from another country? nullIf yes:Date: N/ACountry: Not AvailableReason: N/Ad. Has a visa ever been denied? null8. Have you traveled to countries outside of the nullIf yes, what countries outside of the have you traveled to?

9 Include dates and howlong you were in the country:Country and Town orCityDatesLength ofStayPurpose ofVisitPerson(s) TraveledWith9. Marital Status: nullSpouse/Registered Domestic Partner(s):Initial here to indicate that you have provided complete and accurate information for thissection:_____4 of 25II. Residence Record10. Starting with your present address and working back, list each address (includingtemporary addresses) at which you have resided. Please include military and college(campus and/or off-campus) addresses. All foreign addresses must be included: :AptNo.: city orTown:County:State:ZipCode:Country:a. Do you own or co-own any Real Estate?

10 : nullb. All Residence telephone number(s) ever used: (Area Code)____-_____c. All Cell phone number(s) ever used: (Area Code) ____-_____ N/Ad. All email address(es) ever used: N/Ae. Do you have an account on a social networking website, such as MySpace, Facebook,or Twitter? nullIf yes, indicate address(es): N/AInitial here to indicate that you have provided complete and accurate information for thissection:_____5 of 25 III. Family Record11. Do you have any children? nullIf yes, list below all of your living or deceased children, including natural, adopted,and/or foster care. Include any other children who have ever resided with you. Providethe name and contact information of the other parent or guardian:a.