Capitol Police
Office of Criminal Justice Assistance
Emergency Management/Homeland Security
State Fire Marshal
Records, Communication and Compliance
Highway Patrol
Investigations
Office of Professional Responsibility
Office of Traffic Safety
Training
Emergency Response Commission
Office of Cyber Defense Coordination
Parole and Probation
Background Investigation Unit
555 Wright Way
Carson City, Nevada 89711
Telephone (775) 684-4836 Fax (775) 684-4845
www.dps.nv.gov
CIVILIAN APPLICANT
BACKGROUND INVESTIGATION PROCEDURES
Dear Applicant:
Congratulations! You have successfully completed the interview stage for a position with the Department of
Public Safety. You will now advance to the next phase of our selection process, the background investigation.
The Department of Public Safety seeks to employ only those individuals who are most qualified. Towards this
effort, we insist upon impeccable moral character, uncompromising integrity, and the possession of certain
attributes common to all successful applicants.
We have identified the attributes or job dimensions that must be met before an applicant may be appointed to
a position within our department. The job dimensions for the position you have applied for are:
1. Communication skills
2. Problem solving ability
3. Learning ability
4. Judgment under pressure
5. Observational skills
6. Willingness to confront problems
7. Interest in people
8. Interpersonal sensitivity
9. Desire for self-improvement
10. Dependability
11. Integrity/honesty
In an effort to determine your ability to meet these job dimensions, an extensive background investigation
will be conducted. This background investigation is intended to help us verify the information you provide in
your Personal History Statement (PHS). Be thorough, legible, accurate and honest in completing your
PHS. Omissions, inaccuracies, or incomplete information can be cause for rejection from the
background process. Please be sure to have your fingerprint cards completed at your local law
enforcement agency or LiveScan (see instructions for further information) vendor and fill in your
pertinent information in blue ink. Your background investigation cannot be completed without the
processing of your fingerprint cards or LiveScan results.
Pursuant to Nevada Administrative Code 284.718 and Nevada Administrative Code 284.726,
confidentiality is imperative. Therefore, the findings of the background investigation will only be used to
determine your suitability for employment with the Department of Public Safety.
Brian Sandoval
Governor
James M. Wright
Director
Patrick Conmay
Acting Deputy Director
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The information gathered from you, obtained from third party sources (references, employers, co-workers,
etc.), or discovered during the investigation will not be released to other persons or agencies unless they
present this Department with a signed, notarized release from you. In addition, all information we obtain
during the course of the investigation will not be released to you at any time.
An exception to this confidentiality will be made if it is discovered you are currently involved in
criminal activity or have committed an undiscovered felony. The law enforcement agency having jurisdiction
will be notified.
Complete the Personal History Statement on your own and return all the accompanying documents within
two weeks (sooner if possible) or by the date established by the hiring manager. The completed PHS should
be submitted to:
Department of Public Safety
Background Investigation Unit
555 Wright Way
Carson City, NV 89701
NOTE: Your background investigation will be closed if you fail to respond to your assigned Background
Investigator’s attempts to contact you within 10 days.
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State of Nevada Department of Public Safety
SELECTION CRITERIA
CIVILIAN APPLICANT
1. Automatic Rejection Elements: Factors discovered during an applicant background by interview or
investigation.
A. Any violation of public trust while previously employed in law enforcement or other public
service.
B. Intentional falsification, deception, or omission of information during the application and
background investigation process.
2. Possible Rejection Elements: The following factors will be considered on a case by case basis and may
serve as the basis for rejection.
A. A conviction of a felony in this State or a conviction in another state which would be a felony if
committed in this State.
B. A conviction of any offense involving the illegal use, sale, or manufacture of controlled
substances.
C. Conviction of one D.U.I. within the last five (5) years, or two (2) D.U.I. convictions in a lifetime.
D. Has a documented history of physical violence.
E. Has a domestic violence conviction.
F. Any illegal use of a controlled substance within one year of the date of application.
G. The discovery of an undisclosed crime that would adversely affect the applicant’s work
performance.
H. Convictions of gross misdemeanor in this State or any offense in another State which would be
considered as such if committed in this State.
I. Conviction of an offense resulting in incarceration.
J. Suspension, revocation or cancellation of a driver’s license within three (3) years of the date of
application, or two (2) or more suspensions, revocations or cancellations.
K. Three (3) or more hazardous traffic violations within three (3) years of the date of
application.
L. Fraudulent use of employment or sick leave within ten (10) years of the date of application.
M. Termination for cause from a previous employer.
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N. Separation from the United States Armed Forces under less than “honorable” conditions having a
basis in misconduct.
O. Unfavorable recommendations from past or present references, employers, or landlords.
P. A history of sporadic or inconsistent employment.
Q. A history of alcohol or controlled substance abuse, which has hampered job performance within
five (5) years of the date of application.
R. Any affiliation with and/or support of any organization or group which advocates the violent
overthrow of the State or United States government, or whose professed goals are contrary to the
interest of the public safety and welfare.
S. Any conclusion by an appointing authority that the applicant is unsuitable for work in a law
enforcement environment.
T. Any factor or combination of factors, which would limit or prohibit the applicant from
functioning successfully as a member of the Department of Public Safety, or would be
detrimental to the Department.
3. The Director, or his designee, may at his/her discretion override any of the criteria set forth above.
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INSTRUCTIONS FOR COMPLETING THE
PERSONAL HISTORY STATEMENT
1. The completion of the Personal History Statement is mandatory. Please read all instructions carefully.
The ability to follow instructions in an accurate, thorough and timely manner is part of the background
investigation process. Rejection from this process may occur if the Personal History Statement is not
completed properly.
2. Answer all questions truthfully and completely. Those factors in your background which could be
considered negative will be evaluated based on the specific circumstances and facts surrounding the
incident. All factors will be scrutinized to determine their degree of relevance to the job dimensions for
the position in which you have applied.
3. Any deliberate omission, lie, falsification or fraudulent response will automatically and irrevocably
result in your rejection from the background investigation process and you will not be considered for
placement. Be sure to sign the page title Drug Use Questionnaire, Continued even if not applicable.
Ensure that you read and understand the Penalty and Certification clause on the last page of the Personal
History Statement before signing.
4. Answer ALL questions completely. Be sure to include full addresses, zip codes, area codes, etc. If the
question does not apply to you, enter “N/A” (not applicable) in the appropriate space. If you do not
know the answer to the question, enter “UNK” (unknown) in the appropriate space. It is imperative that
you reply to every question in the Personal History Statement. Do not leave blanks. Again, failure to
complete the Personal History Statement may cause rejection.
5. If you require more space to answer a question completely, a continuation page has been provided. If
this page is not sufficient, attach additional 8-1/2 x 11 inch, white sheets of paper to the back of the
Personal History Statement. Be sure to identify which question you are answering by its correct number.
6. Print (do not use cursive) all of your answers in blue ink.
7. The original Personal History Statement will not be returned to you. Retain a copy for your records.
Disclosure of Medically-Related Information
In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring
process applicants are not expected or required to reveal any medical or other
disability related information about themselves in response to questions on this form or
to any other inquiry made prior to receiving a conditional offer of employment.
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PAGE 1 OF 17
SECTION 1: PERSONAL
1. YOUR FULL NAME
LAST
FIRST
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
7. BIRTH PLACE (CITY/COUNTY/STATE/COUNTRY)
8. BIRTHDATE
9. SOCIAL SECURITY NUMBER
- -
10. DRIVER’S LICENSE
NO
STATE
EXP
11. PHYSICAL DESCRIPTION
HEIGHT WEIGHT HAIR COLOR EYE COLOR
12. Tattoos; scars; other identifying marks; carefully describe the nature/subject; color and location of the tattoo. If more space is needed continue your response on page 16.
SECTION 2: RELATIVES
13. IMMEDIATE FAMILY
Provide all applicable information in the spaces below
Circle “N/A” if a category is not applicable or if the individual is deceased. If the individual is deceased, please list his or her name.
If more space is needed continue your response on page 16.
N/A
A. FATHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
B. STEP-FATHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
C. MOTHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A
D. STEP-MOTHER
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
NAME
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 2 OF 17
SECTION 2: RELATIVES Continued
13. IMMEDIATE FAMILY continued
N/A E. SPOUSE / REGISTERED DOMESTIC PARTNER / SIGNIFICANT OTHER
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A F. FATHER-IN-LAW
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A G. MOTHER-IN-LAW
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
N/A H. FORMER SPOUSE(S) / FORMER REGISTERED DOMESTIC PARTNERS(S) / FORMER SIGNIFICANT OTHERS
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
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
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
2) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
3) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 3 OF 17
SECTION 2: RELATIVES Continued
13. IMMEDIATE FAMILY (Section I. Brothers and Sisters) continued
4) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
5) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
6) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
M
F
UNDER AGE 18
WORK PHONE
OCCUPATION
HOME 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)
CHILD’S AGE
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
2) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
3) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
4) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
5) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
6) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE
ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
CONTACT NUMBER
EMAIL
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 4 OF 17
SECTION 3: REFERENCES: List 5 people who know you well, such as social and family friends, co-workers, military acquaintances. DO
NOT list relatives, employers, housemates, co-workers, or any other individuals listed in another section.
A) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
B) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
C) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
D) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
E) NAME
HOME ADDRESS (NUMBER/STREET/APT) CITY STATE ZIP
WORK PHONE
OCCUPATION
HOME PHONE
CELL PHONE
EMAIL
HOW DO YOU KNOW THIS PERSON? FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND)
HOW LONG HAVE YOU KNOW THIS PERSON?
SECTION 4: EDUCATION
15. CHECK APPLICABLE:
High School Diploma from an accredited U.S. Institution
GED
High School Proficiency Certificate
16. LIST HIGH SCHOOLS ATTENDED:
A) NAME
FROM (MO/YR)
TO (MO/YR)
DEGREE EARNED
CITY
STATE
B) NAME
FROM (MO/YR)
TO (MO/YR)
DEGREE EARNED
CITY
STATE
C) NAME
FROM (MO/YR)
TO (MO/YR)
DEGREE EARNED
CITY
STATE
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PAGE 5 OF 17
SECTION 4: EDUCATION Continued
17. LIST COLLEGES ATTENDED:
A) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
CITY
STATE
B) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
CITY
STATE
18. LIST TRADE SCHOOLS ATTENDED:
A) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
TYPE OF SCHOOL OR TRAINING
CITY
STATE
B) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
TYPE OF SCHOOL OR TRAINING
CITY
STATE
C) NAME
FROM (MO/YR)
TO (MO/YR)
TOTAL UNITS EARNED
TYPE OF SCHOOL OR TRAINING
CITY
STATE
19. Have you ever been placed on academic discipline/probation, suspended or expelled from any high school, college/university, business
or trade school? ……………………………………………………………………………………………………………………………..
YES NO
SECTION 5: RESIDENCE
20. LIST OF RESIDENCES:
List all residences during the last 5 years or singe the age of 18, in descending order. Provide complete addresses (include markers such as Street, Drive,
Road, East, West, etc., and the unit or apartment number). Do not use P.O. Boxes.
If the residence is a Military Base, identify the name of the base in the address line, include nearest city, state and zip code. DO NOT LIST Military barrack
mates unless you shared individual quarters.
If more space is needed continue your responses on page 16.
A) ADDRESS WHERE YOU LIVE NOW (NUMBER/STREET/APT)
FROM (MO/YR)
TO
PRESENT
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
B) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 6 OF 17
SECTION 5: RESIDENCE Continued
C) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
D) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
E) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
F) FORMER ADDRESS (NUMBER/STREET/APT)
FROM (MO/YR)
TO (MO/YR)
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR OR OWNER
CONTACT NUMBER
CITY
STATE
ZIP
EMAIL
NAME OF THOSE WITH WHOM YOU LIVED:
REASON FOR MOVING:
21. Have you ever been evicted or asked to leave a residence?
………………………………………………………………………………
YES NO
22. Have you ever left a residence owing rent? ………………………………………………………………………………………………… YES NO
If you have answered “YES” to Questions 21 and/or 22, explain (include, when, where and circumstances):
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 7 OF 17
SECTION 6: EXPERIENCE AND EMPLOYMENT
23. JOB EXPERIENCE
List ALL jobs you have had during the last TEN years. Including part-time, temporary, self-employment and volunteer work. Begin with your most current
employment. If more space is needed continue your response on page 16.
If you have military experience, including Reserve duty, enter your military base, assignments or unit of assignment.
List ALL periods of unemployment during the last TEN years.
A) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
Would there be a problem if we
contact your current employer?
YES NO
IF YES, EXPLAIN:
B) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
C) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
D) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
E) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
F) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 8 OF 17
SECTION 6: EXPERIENCE AND EMPLOYMENT Continued
G) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
H) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
I) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
J) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
K) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
L) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 9 OF 17
SECTION 6: EXPERIENCE AND EMPLOYMENT Continued
M) NAME OF EMPLOYER OR MILITARY UNIT
FROM (MO/YR)
TO (MO/YR)
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T TEMP
SELF-EMPLOYED VOLUNTEER
NAMES OF CO-WORKERS & DAYTIME PHONE NUMBERS
REASON FOR WANTING TO LEAVE
1)
2)
N) PERIOD OF UNEMPLOYMENT
CIRCLE APPLICABLE:
STUDENT
BETWEEN
JOBS
LEAVE OF
ABSENCE
TRAVEL OTHER
FROM (MO/YR)
TO (MO/YR)
24. Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling, reprimands, suspensions,
reductions in pay, reassignments or demotions) ……………………………………………………………………………………….......
YES NO
25. Have you ever been fired, released from probation, or asked to resign from any place of employment? …………………………………. YES NO
26. Were you ever involved in a physical or verbal altercation with a supervisor, co-worker, or customer? ……………………………….. YES NO
27. Have you ever quit without giving proper notice? ……………………………………………………………………………………….. YES NO
28. Have you ever resigned in lieu of termination? …………………………………………………………………………………………….. YES NO
29. Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.) by a co-
worker, superior, subordinate of customer? ……………………………………………………………………………………………......
YES NO
30. Have you ever been the subject of a written complaint at work? …………………………………………………………………………... YES NO
31. Have you ever been counseled at work due to tardiness or absences? ……………………………………………………………………... YES NO
32. Have you ever received an unsatisfactory performance review? ………………………………………………………………………….. YES NO
33. Have you ever sold, released, or given away legally confidential information? ……………………...……………………………………. YES NO
34. Have you ever called in sick when you were neither sick nor caring for a sick family member?
..................................................................
YES NO
If Yes, how many sick days have you used in the past five (5) years which were not due to illness?
If you have answered “YES” to Questions 24 - 34, explain (include, when, where and circumstances):
35. Have you ever missed days or been late to work due to drug or alcohol consumption? ……………………………………………………
YES NO
If yes, how often?
36. Has your work performance ever been affected by your use of drugs or alcohol? ………………………………………………………… YES NO
WHEN?
NAME OF EMPLOYER
37. Have you ever been warned by an employer about your drinking or drug habits and their impact of your performance? ………..…… YES NO
WHEN?
NAME OF EMPLOYER
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 15 of 30
PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 10 OF 17
38. Have you ever applied to any other law enforcement agency (city, county, state or federal)? ……………………………………………..
If yes, list every agency you have applied to, starting with the most recent. Give complete and accurate addresses.
All agencies must be listed regardless of the outcome or current status. Circle the steps/status as they apply for each agency.
If more space is needed, continue your response on page 16.
YES
NO
A) NAME OF AGENCY
DATE APPLIED (MO/YR)
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process you have COMPLETED and your current status
STEPS:
APPLICATION
WRITTEN
EXAM
PHYSICAL
ABILITY EXAM
ORAL BOARD
POLYGRAPH/
CVSA
BACKGROUND
INVESTIGATION
CHIEF’S
ORAL
CONDITIONAL
JOB OFFER
STATUS:
HIRED ON LIST WITHDRAWN DISQUALIFIED
B) NAME OF AGENCY
DATE APPLIED (MO/YR)
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process you have COMPLETED and your current status
STEPS:
APPLICATION
WRITTEN
EXAM
PHYSICAL
ABILITY EXAM
ORAL BOARD
POLYGRAPH/
CVSA
BACKGROUND
INVESTIGATION
CHIEF’S
ORAL
CONDITIONAL
JOB OFFER
STATUS:
HIRED ON LIST WITHDRAWN DISQUALIFIED
C) NAME OF AGENCY
DATE APPLIED (MO/YR)
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process you have COMPLETED and your current status
STEPS:
APPLICATION
WRITTEN
EXAM
PHYSICAL
ABILITY EXAM
ORAL BOARD
POLYGRAPH/
CVSA
BACKGROUND
INVESTIGATION
CHIEF’S
ORAL
CONDITIONAL
JOB OFFER
STATUS:
HIRED ON LIST WITHDRAWN DISQUALIFIED
SECTION 7: MILITARY EXPERIENCE
39. Are you required to register for the Selective Service? ……………………………………………………………………………………..
YES
NO
If yes, have you registered? ……………………………………………………………………………………………………………….
YES
NO
If no, explain:
40.BRANCH OF SERVICE
41. DATES OF SERVICE
FROM (MO/YR) TO (MO/YR)
41. TYPE OF
DISCHARGE:
ENTRY LEVEL HONORABLE GENERAL OTH (OTHER THAN HONORABLE) BAD CONDUCT DISHONORABLE
RE-ENTRY CODE (1-4) IF APPLICABLE REFER TO YOUR DD-214:
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 11 OF 17
SECTION 7: MILITARY EXPERIENCE Continued
42. Are you currently participating in one of the following? Military Reserve National Guard Date your obligation ends:
43. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as court martial, captain’s mast, office hours,
and/or company punishment)? ……………………………………………………………………………………………………………..
YES NO
44.
Were you ever denied security clearance or have you had your clearance revoked, suspended or downgraded? ………………………….
YES NO
45. Have you ever been reduced in rank as punishment? ………………………………………………………………………………………. YES NO
If you have answered “YES” to Questions 43 - 45, explain (include, when, where and circumstances):
SECTION 8: LEGAL
DISCLOSURES OF ARRESTS AND CONVICTIONS
This section requires you to report detentions, arrests and convictions, including diversion programs that were not successfully completed and in some
cases offenses which may have been pardoned. It is strongly recommended you consult with an attorney before omitting any information.
46. Have you ever been detained for investigation, held on suspicion, questioned, fingerprinted, arrested, indicted, criminally charged, or
convicted of any misdemeanor or felony offense in this state or in any other legal jurisdiction (including offenses punishable under the
uniform code of Military Justice)? …………………………………………………………………………………………………………
YES
NO
If yes explain each incident in the spaces below, If more space is needed continue your response on page 16.
A) APPROXIMATE DATE (MO/YR)
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
B) APPROXIMATE DATE (MO/YR)
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
C) APPROXIMATE DATE (MO/YR)
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 12 OF 17
SECTION 8: LEGAL
Continued
47. Have you ever been placed on court probation as an adult? ………………………………………………………………………………... YES NO
48. Were you ever required to appear before a juvenile court for an act which would have been a crime if committed as an adult? ………..... YES NO
49. Have you ever been a party in a civil lawsuit (e.g. divorce, small claims actions, child/spousal support, etc.)? …………………...……… YES NO
50. Have the police ever been called to your home for any reason? ……………………………………………………………………….…… YES NO
51. Have you or your spouse/partner ever been referred to Child Protective Services? ……………………………………………………...… YES NO
52. Do you currently of have you ever had any association with persons convicted/charged with crimes categorized as a felony? ………..
YES
NO
If yes, please provide the person’s full name, relationship, frequency of contact and charges convicted of, in the space provided.
53. Have you ever been the subject of an emergency protective order, restraining order or stay-away order? ………………………………… YES NO
54. Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf was required to make a payment to
another party? ….............................................................................................................................................................................................
YES NO
55. Have you ever fraudulently received welfare, unemployment compensation, worker’s compensation, or other state of federal
assistance? …………………………………………………………………………………………………………………………………...
YES NO
56. Have you ever filed a false insurance or worker’s compensation claim? ………………………………………………………………… YES NO
If you have answered “YES” to Questions 24 - 34, explain (include, when, where and circumstances):
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 13 OF 17
SECTION 9: DRUG USE
Questions 57 and 58 relate to your current and past recreational drug use. This covers the use of any drug, including the unauthorized use of prescription or over-the-
counterdrugs. Your answers should include, but not be limited to, your use of any of the following drugs:
AMPHETAMINES /
METHAMPHETAMINES
(UPPERS, SPEED, CRANK, ETC.)
HALLUCINOGENS
(PEYOTE, LSD, MUSHROOMS)
PHARMACEUTICAL DRUGS NOT
PRESCRIBED TO YOU
BARBITURATES (DOWNERS) HASHISH / HASHISH OIL PCP / ANGEL DUST
COCAINE / CRACK COCAINE HEROIN / OPIUM QUAALUDES
DESIGNER DRUGS
(ECSTASY, SYNTHETIC HEROIN, ETC.)
MARIJUANA STEROIDS
GHB
(DATE RAPE DRUG)
MESCALINE TETRAHYDROCANNABINOL (THC)
GLUE MORPHINE
OTHER ILLEGAL OR CONTROLLED
SUBSTANCES
57. In your lifetime, have you used any drug(s) as indicated above? …………………………………………………………..……………
YES
NO
If you answered “YES” to question 57, give details, including drug(s) used, dates used and the circumstances involved:
58. I have never used any drugs…………………………………………………………………………………………………………………. YES NO
59. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including marijuana?
SOLD PURCHASED CULTIVATED
MANUFACTURED FURNISHED CARRIED OR HELD FOR ANOTHER
If you circled any of the items above, give details including drug(s) involved, over what time period’s and circumstances:
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 14 OF 17
SECTION 10: MOTOR VEHICLE OPERATION
60. CURRENT DRIVER’S LICENSE NUMBER
STATE OF ISSUE
EXPIRATION DATE
NAME UNDER WHICH LICENSE WAS GRANTED
61.LIST OTHER STATED WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE:
STATE OF ISSUE TYPE OF LICENSE NAME UNDER WHICH LICENSE WAS GRANTED AND NUMBER IF KNOWN
62. Have you ever been refused a driver’s license by any state? ……………………………………………………………………………….. YES NO
If you have answered “YES”, explain (include when, where and circumstances):
63. Has your driver’s license ever been suspended or revoked? ……………………………………………………………………………….. YES NO
If you have answered “YES”, explain (include when, where and circumstances):
64. List all traffic citations, excluding parking citations; you have received in the past ten (10) years. If more space is needed, continue your response on page 16.
A) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED ACTION TAKEN (CIRCLE ALL THAT APPLY)
MONTH YEAR NOT GUILTY FINED TRAFFIC SCHOOL DISMISSED
B) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED ACTION TAKEN (CIRCLE ALL THAT APPLY)
MONTH YEAR NOT GUILTY FINED TRAFFIC SCHOOL DISMISSED
C) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED ACTION TAKEN (CIRCLE ALL THAT APPLY)
MONTH YEAR NOT GUILTY FINED TRAFFIC SCHOOL DISMISSED
D) Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following? (Circle all that apply)
FAILURE TO APPEAR FAILURE TO COMPLETE TRAFFIC SCHOOL FAILURE TO PAY THE REQUIRED FINE
If circled, explain circumstances:
65. Have you been involved as the driver in a motor vehicle accident with the past ten (10) years? …………………………………………..
YES NO
If yes, give details below:
A) DATE
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY NON-INJURY
B) DATE
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY NON-INJURY
C) DATE
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY NON-INJURY
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 15 OF 17
66. Have you ever driven a vehicle without automobile insurance as required by law? ……………………………………………………….. YES NO
If you have answered “YES”, give reason:
DATE VIOLATION OCCURRED
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
MONTH YEAR
67. Have you ever driven a vehicle without automobile insurance as required by law? ……………………………………………………….. YES NO
If you have answered “YES”, give reason:
INSURANCE COMPANY:
DATE VIOLATION OCCURRED
LOCATION (NUMBER /STREET/APT) CITY STATE ZIP
MONTH YEAR
Use this space for additional information you would like to include regarding your driving record:
SECTION 11: OTHER TOPICS
68. Have you ever been refused a permit to carry a concealed weapon? ……………………………………………………………………….. YES NO
69. Are you now or have you ever been, a member or associate of a criminal enterprise, street gang or any other group which advocated
violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality, gender, sexual preference or
disability? …………………………………………………………………………………………………………………………………...
YES NO
70. Do you have, or have you ever had, a tattoo signifying membership in or affiliation with a criminal enterprise, street gang or any other
group which advocated violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,
gender, sexual preference or disability? …………………………………………………………………………………………………….
YES NO
71. Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or violent act?.................................. YES NO
72. Have you ever hit or physically overpowered a spouse or romantic partner? …………………………………………………………… YES NO
If you have answered “YES” to any of Questions 68-72, give details including dates and circumstances; identify the corresponding question being referenced:
SECTION 11: CERTIFICATION
73. I hereby certify I have personally completed each page of this form and any supplemental page(s) attached and all statements made are true and complete to the best
of my knowledge and belief. I understand any misstatement of material fact may subject me to disqualification or if I have been appointed, may disqualify me from
continued employment.
SIGNATURE IN FULL
DATE
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PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 16 OF 17
SECTION 11: ADDITIONAL SPACE
Use this space to provide information that does not fit elsewhere on this form (e.g. additional family members, schools, residences, employers, explanations to
questions, etc.). Identify the corresponding question and specific item number being referenced.
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 22 of 30
PERSONAL HISTORY STATEMENT CIVILIAN APPLICANT
PAGE 17 OF 17
Please complete this page in your own handwriting.
Question: “Why do you want this job? How do you think it will benefit you and the agency?”
PENALTY AND CERTIFICATION
I HEREBY CERTIFY THERE ARE NO WILLFUL MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS IN THE FOREGOING STATEMENTS AND
ANSWERS TO THE QUESTIONS. ALL STATEMENTS AND ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER
UNDERSTAND FALSIFYING, WITHHOLDING OR FAILING TO ANSWER ANY AND ALL QUESTIONS COMPLETELY AND ACCURATELY MAY
CAUSE REJECTION FROM CONSIDERATION FOR THE POSITION TO WHICH I AM APPLYING.
SIGNATURE
DATE
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 23 of 30
REQUIRED DOCUMENT LIST
CIVILIAN POSITION
The below listed documents are to be provided by the applicant. These documents, along with this checklist, must
be submitted with
the Personal History Statement. Place a check mark in the spaces provided to the left of this form
to verify the required documents
have been obtained. If a particular document does not apply to you, indicate “N/A”
in the space provided. YOU MUST OBTAIN
ALL REQUIRED DOCUMENTS OR EXPLAIN IN WRITING
WHY YOU DID NOT. FAILURE TO DO SO MAY
RESULT IN THE REJECTION OF YOUR
APPLICATION.
1. Original Waiver of Liability and Release Form Notarized.
2. Las Vegas Metro Police Department (LVMPD) Waiver Notarized (Complete this form whether or not you have
applied with the LVMPD).
3. Request Pertaining to Military Records Standard Form 180 (Mandatory This form must be completed regardless
if you have served in the military or not. You must complete "Section 1" and this form must be signed "Section 3."
If you have served in the military please check the appropriate boxes).
4. Fingerprint Request Form Must be completed and returned completed & signed by agency taking fingerprints (If
you live outside the state of Nevada Mail the hard copy fingerprint cards to: DPS Background Investigation Unit
555 Wright Way Carson City, Nevada 89701).
5. Fingerprint Background Waiver Complete and Sign the Form.
6. Birth Certificate or other official proof of birth.
7. Copy High School Diploma or Transcripts
8. Copy of College Diploma or Transcripts
9. Military Discharge Long Form DD-214 (if applicable).
10. Police Reports You must provide all police reports you have been named in, or referred to by all law enforcement
agencies in which you were either a victim, suspect, person of interest, or similar. You are responsible for obtaining
and providing the reports. Your background investigator will complete multiple searches to verify you have
provided all reports you have been named in.
11. Copy of any active Temporary Restraining Order or Temporary Protection Order issued on your behalf or filed
against you.
12. Any other Documents, Certificates, Awards or Commendations you believe may be located during the background
investigation process, or documents showing your skills, abilities, etc. you would like the agency to be aware of.
CERTIFICATION
I hereby certify I have read and understood the above information. I further understand failure to provide
the necessary
documents or offering fictitious/erroneous statements may result in the rejection of my application.
Applicant’s name (print)
Applicant’s Signature Date
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 24 of 30
Human Resources
555 Wright Way
Carson City, NV 89701
PRE-EMPLOYMENT WAIVER AND LIABILITY
RELEASE
In consideration for the processing of my application for
the position of ,
(Position)
with the . I,
,
(Agency) (Applicant Name)
do hereby irrevocably agree to the following:
WAIVER OF LIABILITY
I hereby release from liability and promise to hold harmless under and all causes of legal action, the State
of Nevada,
the Department of Public Safety, its agents or employees, and any and all persons or entities in
the pursuance of my
background investigation.
RELEASE OF INFORMATION
I authorize, for a period of two (2) years from the date of signature on this document, any person or entity
contacted by
the State of Nevada, the Department of Public Safety, its agents or employees, during the
course of my background
investigation, to furnish to said persons or entities, any and all information that
they may have concerning me,
including, but not limited to, written examinations, physical agility tests,
interviews, background investigations,
polygraph or other lie detection device results, psychological
evaluations, any confidential or privileged
information, employment personnel files, any sealed data or
materials, or agreed to be withheld information
pursuant to any prior agreement or court proceeding
involving disciplinary matters or any other information or
opinions they may have.
NRS 239B STATES THAT UPON REQUEST OF A LAW ENFORCEMENT AGENCY, AN EMPLOYER SHALL PROVIDE
TO THE LAW ENFORCEMENT AGENCY INFORMATION, IF AVAILABLE, REGARDING A CURRENT OR FORMER
EMPLOYEE OF THE EMPLOYER WHICH IS AN APPLICANT FOR THE POSITION OF PEACE OFFICER WITH THE
LAW ENFORCEMENT AGENCY. FURTHERMORE, NRS 41.755 STATES…AN EMPLOYER WHO DISCLOSES
INFORMATION REGARDING AN EMPLOYEE TO A LAW ENFORCEMENT AGENCY PURSUANT TO SECTION 1
OF THIS ACT IS IMMUNE FROM CIVIL LIABILITY FOR SUCH DISCLOSURE AND ITS CONSEQUENCES.
INVESTIGATION DISCOVERY WAIVER
Pursuant to NAC 284.718 and NAC 284.726, confidentiality is imperative. Therefore, I hereby waive,
without
reservation, any right I may have, now or in the future, to examine, review or otherwise discover
the contents of this
background investigation and all related documents thereto. This waiver shall apply
to any right of action of any
nature whatsoever, that may accrue to myself, my heirs, or my personal
representative(s).
Dated this day of ,
Signature of Person Waiving Rights
Subscribed and Sworn before me this day of ,
Signature of Notary (Notary Seal)
Notary public in and for said county of
State of
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 25 of 30
WAIVER OF LIABILITY AND AUTHORIZATION TO RELEASE INFORMATION
TO LAS VEGAS METROPOLITAN POLICE DEPARTMENT:
I, , hereby authorize you to furnish the Nevada
Department of Public Safety any and all information concerning my employment with LAS VEGAS
METROPOLITAN POLICE DEPARTMENT, any information, background investigation information,
psychological and polygraph test results (pass or fail only), that was obtained as a result of my application
for employment with the LAS VEGAS METROPOLITAN POLICE DEPARTMENT. Information of a
confidential or privileged nature may be included.
FURTHERMORE, I hereby release LAS VEGAS METROPOLITAN POLICE DEPARTMENT of any and all
liability or damage which may result by furnishing the information requested by the above-named organization
on my behalf.
DATED this day of .
(Signature)
Subscribed and sworn before me this day of .
Notary Public, in and for
County of
State of
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Standard Form 180 (Rev. 11/2015) (Page 1)
Prescribed by NARA (36 CFR 1233.18(d))
Authorized for local reproduction
Previous editions unusable
OMB No. 3095-0029 Expires 04/30/2018
REQUEST PERTAINING TO MILITARY RECORDS
Requests from veterans or deceased veteran’s next-of-kin may be submitted online by using eVetRecs at http://www.archives.gov/veterans/military-service-records/
To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW
SECTION I INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible)
1. NAME USED DURING SERVICE (last, first, full middle)
2. SOCIAL SECURITY #
3. DATE OF BIRTH
4. PLACE OF BIRTH
5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.)
BRANCH OF SERVICE
DATE
ENTERED
DATE
RELEASED
OFFICER ENLISTED
SERVICE NUMBER
(If unknown write “unknown”)
a. ACTIVE
b. RESERVE
c. STATE
NATIONAL
GUARD
6. IS THIS PERSON DECEASED?
NO
YES MUST PROVIDE Date of Death if veteran is deceased:
7. DID THIS PERSON RETIRE FROM MILITARY SERVICE?
NO
YES
SECTION II INFORMATION AND/OR DOCUMENTS REQUESTED
1. CHECK THE ITEM(S) YOU ARE REQUESTING:
DD 214 Form or equivalent. Year(s) in which form (s) issued to veteran:
This form contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran’s next-of-kin, or other persons or organizations, if authorized
in Section III, below. An UNDELETED DD214 is ordinarily required to determine eligibility for benefits. If you request a DELETED copy, the following items will be blacked out.
Authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and, for separations after June 30, 1979, character of separation and dated of time lost.
An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box:
I want a DELETED copy.
Medical Records Includes Service Treatment Records, Health (outpatient) and Dental Records. IF HOSPITALIZED (inpatient) the FACILITY NAME and
Date (month and year) for EACH admission MUST be provided:
Other (Specify):
ALL DOCUMENTS IN OFFICIAL MILITARY PERSONNEL FILE (OMPF)
2. PURPOSE:
(Providing information about the purpose of the request is strictly voluntary; however, it may help to provide the best possible response and may result in a faster reply. Information provided will
in no way be used to make a decision to deny the request.)
Benefits (explain) Employment VA Loan Program Medical Genealogy Correction Personal Other (explain)
Explain here:
PRE-EMPLOYMENT BACKGROUND INVESTIGATION
SECTION III RETURN ADDRESS AND SIGNATURE
1. REQUESTER NAME:
2.
I am the MILITARY SERVICE MEMBER OR VETERAN identified in Section I
above.
I am the VETERAN’S LEGAL GUARDIAN (MUST submit copy of Court
Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit
copy of Authorization Letter or Power of Attorney)
I am the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit Proof of
Death. See item 2A on instructions sheet.)
OTHER
(Relationship to deceased Veteran)
(Specify type of Other)
3. SEND INFORMATION/DOCUMENTS TO:
(Please print of type. See item 4 on accompanying instructions.)
4. AUTHORIZATION SIGNATURE: I declare (or certify, verify, or state) under penalty of
perjury under the laws of the United States of America that the information in this Section III
is true and correct and that I authorize the release of the requested information. (See items 2a
or 3a on accompanying instruction sheet. Without the Authorization Signature of the veteran, next-
of-kin of deceased veteran, veteran’s legal guardian, authorized government agent, or other
authorized representative, only limited information can be released unless the request is archival. No
signature id required if the request is for archived records.)
NEVADA DPS, BACKGROUNDS INVESTIGATION UNIT
Name
555 WRIGHT WAY
Street
CARSON CITY
NV
89701
City
State
Zip Code
Signature Required Do Not Print
Date
* This form is available at http://www.archives.gov/veterans-military-service-
records/standard-form-180.pdf on the National Archives and Records Administration
(NARA) web site.*
Daytime Phone
Fax Number
Email Address
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 27 of 30
Background Investigation Unit
555 Wright Way
Carson City, Nevada 89701-0525
Telephone (775) 684-4836 Fax (775) 684-4845
FINGERPRINT REQUEST FORM
Please provide this form to the fingerprint technician/official at time your fingerprints are taken to ensure all fields contain
the required/authorized information needed for processing. Once you have been fingerprinted upload the completed and
signed form into the correct location within the Agreements folder. Save the original hardcopy as you may be asked for it
at a later time.
APPLICANT INFORMATION:
APPLICANT NAME: (LAST, FIRST, MI)
_____________________________________________________________________________________________
APPLICANT ADDRESS:
_____________________________________________________________________________________________
CITY, STATE, ZIP CODE:
_____________________________________________________________________________________________
DATE OF BIRTH: ________________________ PLACE OF BIRTH: __________________________
SSN: ___________________________________ CITIZENSHIP: ______________________________
SEX: _______ RACE: ________ HGT: ________ WGT: ________ EYES: ________ HAIR: ________
ACCOUNT NUMBER (MNU): NUF947 ORI: NVDPS0000
REASON FINGERPRINTED: CRIMINAL JUSTICE APPLICANT
SUBMIT FINGERPRINT ELECTRONIC LIVESCAN: YES: ________ NO: ________
FINGERPRINT SITE INFORMATION:
TCN: _________________________________________________________________________________________
The above-named individual was fingerprinted and said prints will be sent electronically to the Central Repository for Nevada Records
of Criminal History on behalf of the State of Nevada Department of Public Safety.
_________________________________________________
____________________
SIGNATURE OF OFFICIAL TAKING PRINTS DATE
James M. Wright
Director
Patrick Conmay
Acting Deputy Director
Brian Sandoval
Governor
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Fingerprinting Contact Information for the State of Nevada, Department of Public Safety Employment
Appointment Point of Contact for Northern and Southern Nevada
Southern Nevada Fingerprint Unit
Parole & Probation
DONS Unit
(702) 486-5176
215 East Bonanza Road
Las Vegas, NV 89101
Northern Nevada Fingerprint Unit
General Services
Fingerprint Unit
(775) 684-6262
333 West Nye Lane
Carson City, Nevada 89706
If you reside outside the state of Nevada and cannot make it to one of the abovementioned locations please visit
your local law enforcement agency. You will need to present a blank copy of the Fingerprint Request to your
local law enforcement agency for fingerprinting. Please request the fingerprints be submitted electronically to
the prefilled agency account number NUF947 (ORI NVDPS0000) as a criminal justice applicant. If said agency
cannot facilitate an electronic submission please send the hard copies to the address listed below.
Background Investigation Unit
555 Wright Way
Carson City, Nevada 89701
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 29 of 30
FINGERPRINT BACKGROUND WAIVER
As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based criminal
history record check for a noncriminal justice purpose you have certain rights which are discussed below.
1. You must be notified by (name of
requesting agency) that
your fingerprints will be used to check the criminal history records of the FBI and
the State of Nevada.
2. If you have a criminal history record, the officials making a determination of your suitability for the
job,
license or other benefit for which you are applying must provide you the opportunity to complete or
challenge the accuracy of the information in the record. You may review and challenge the accuracy of
any
and all criminal history records which are returned to the submitting agency. The proper forms and
procedures will be furnished to you by the Nevada Department of Public Safety, Records Bureau upon
request. If you decide to challenge the accuracy or completeness of you FBI criminal history record, Title
28 of the Code of Federal Regulations Section 16.34 provides for the proper procedure to do so:
16.34- Procedure to obtain change, correction or updating of identification records. If, after
reviewing his/her identification record, the subject thereof believes that it is incorrect or
incomplete in
any respect and wishes changes, corrections or updating of the alleged deficiency,
he/she should make
application directly to the agency which contributed the questioned
information. The subject of a record
may also direct his/her challenge as to the accuracy or
completeness of any entry on his/her record to the
FBI, Criminal Justice Information Services
(CJIS) Division ATTN: SCU, Mod. D-2, 1000 Custer
Hollow Road, Clarksburg, WV 26306. The
FBI will then forward the challenge to the agency which
submitted the data requesting that
agency to verify or correct the challenged entry. Upon the receipt of an
official communication
directly from the agency which contributed the original information, the FBI
CJIS Division will
make any changes necessary in accordance with the information supplied by that
agency.
3. Based on 28 CFR § 50.12 (b), officials making such determinations should not deny the license or
employment based on information in the record until the applicant has been afforded a reasonable time to
correct or complete the record or has declined to do so.
4. You have the right to expect that officials receiving the results of the fingerprint-based criminal history
record check will use it only for authorized purposes and will not retain or disseminate it in violation of
federal or state statute, regulation or executive order, or rule, procedure or standard established by the
National Crime Prevention and Privacy Compact Council.
0505RCCD-003 (07/2017 rev) Page 1 of 2
Fingerprint Background Waiver
Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 30 of 30
5. I hereby authorize , (name of
requesting agency)
to submit a set of my fingerprints to the Nevada Department Public Safety, Records
Bureau for the
purpose of accessing and reviewing State of Nevada and FBI criminal history records that
may pertain to
me.
In giving this authorization, I expressly understand that the records may include information pertaining to
notations of arrest, detainments, indictments, information or other charges for which the final court
disposition is pending or is unknown to the above referenced agency. For records containing final court
disposition information, I understand that the release may include information pertaining to dismissals,
acquittals, convictions, sentences, correctional supervision information and information concerning the
status of my parole or probation when applicable.
6. I hereby release from liability and promise to hold harmless under any and all causes of legal action,
the
State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records
search and provided information to the submitting agency for any statement(s), omission(s), or
infringement(s) upon my current legal rights. I further release and promise to hold harmless and covenant
not to sue any persons, firms, institutions or agencies providing such information to the State of Nevada on
the basis of their disclosures. I have signed this release voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar process,
shall
for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature voluntarily
appears below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEASE PRINT Last Name First Name Middle
Address:
PLEASE PRINT
Applicant’s Signature:
Date:
Submitting Agency:
Nevada Department of Public Safety – Background Investigation Unit
Address: 555 Wright Way Carson City, Nevada 89701
Agency representative: Johnson, Gina M.
PLEASE PRINT Last Name First Name Middle
Agency Representative’s Signature:
Date: