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Personal History Statement

  1. Western Virginia Regional Jail
    *5885 West River Road Salem, Virginia 24153*
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  3. Personal History Statement
  4. INSTRUCTIONS: Fill out this questionnaire completely and accurately. All statements in your questionnaire are subject to verification. Incorrect statements may bar or remove you from employment. If space provided is inadequate, add to the additional information section at the end of the application. If a question does not apply to you, indicate by writing N/A in the answer blank.
  5. Personal
  6. Were you married before your present marriage?*
  7. Do you have children?*
  8. If yes, list full names and dates of birth of each below, and list addresses where they reside.
  9. List below full names of all immediate relatives such as father, mother, sister, brother, step/half sister, step/half brother. If deceased, give date of death in address space and mark deceased. Give mother's maiden name as her middle name.
  10. References
  11. Give the names of five responsible people, other than relatives or past employers, who could provide information about your character, ability, experience, personality, and other qualities. Please list complete mailing address with zip code and phone number with area code.
  12. Residences
  13. List addresses for the past 20 years, starting with present address. List landlord's name and phone number, if applicable.
  14. Education
  15. Diploma Recieved
  16. Diploma Recieved
  17. Degree Recieved
  18. Degree Recieved
  19. Work History
  20. Have you previously submitted an application with this agency?*
  21. Are you now or ever been engaged in any business as an owner, partner, or corporate board member?*
  22. Have you ever been discharged or forced to resign because of misconduct or unsatisfactory service?*
  23. Do you object to wearing uniforms?*
  24. Do you object to working nights or weekends? *
  25. Do you object to working rotating shifts?*
  26. List all jobs you have held in the last 15 years. Put your present or most recent job first. If you need more space, you may add items to the additional information section at the end of this application. Include military service and part-time jobs in proper time sequence.
  27. A- May we contact this employer?
  28. Full-Time or Part-Time
  29. B- May we contact this employer?
  30. Full-Time or Part-Time
  31. C- May we contact this employer?
  32. Full-Time or Part-Time
  33. D- May we contact this employer?
  34. Full-Time or Part-Time
  35. E- May we contact this employer?
  36. Full-Time or Part-Time
  37. F- May we contact this employer?
  38. Full-Time or Part-Time
  39. G- May we contact this employer?
  40. Full-Time or Part-Time
  41. List the names of any social, fraternal and/or professional organizations of which you are or have been a member. Indicate offices held, if any.
  42. Military Service
  43. Where you ever in the US military service or any other military organization?*
  44. Are you presently a member of the National Guard or any military reserve?*
  45. Were you ever court-martialed, tried on charges, or were you the subject of a summary court, deck court, captain's mast or company punishment, or any other disciplinary action while a member of the armed forces?
  46. Activities
  47. Do you drink alcoholic beverages?*
  48. Have you ever been placed on probation?*
  49. Have you ever been required to pay a fine in excess of $25.00?*
  50. Have you ever used any illegal substances such as marijuana, crack cocaine, or any drug not prescribed by a physician?*
  51. Have you ever sold any amount of illegal drugs?*
  52. Do you presently use any form of illegal drugs?*
  53. Have you ever been arrested or detained for investigation by any law enforcement agency, either as a juvenile or adult?*
  54. If yes, complete the following for each offense:
  55. Have you ever been fingerprinted by a police agency other than for an arrest? Your answer will be checked with the F.B.I. and other agencies:*
  56. If yes, complete the following for each instance:
  57. Driving Information
  58. Can you legally operate a motor vehicle?*
  59. Have you ever been the operator of a motor vehicle involved in an accident which resulted in injury or death to a passenger or pedestrian, or property damage of more than $500?*
  60. Do you possess a valid operator's license from the State of Virginia?*
  61. Do you possess an operator's license issued by any state other than Virginia? If yes, list below.*
  62. Was your Virginia driver's license ever suspended or revoked?*
  63. Was your driver's license from another state ever suspended or revoked?*
  64. Was you driver's license ever restored?*
  65. Have you ever been refused an operator's license by any state?*
  66. Have your driving privileges ever been restricted?*
  67. Has a motor vehicle being driven by you ever been involved in an accident?*
  68. If yes, give complete details for each accident whether collision or non-collision:
  69. Police Investigation?
  70. Police Investigation
  71. Police Investigation
  72. List any convictions for traffic violations:
  73. Attitudes
  74. Career Objectives
  75. Do you know of anything that would disqualify you for appointment as a Correctional Officer, or any other position, or would prevent you from fully discharging the duties of such a position?
  76. Citizenship
  77. Are you a citizen of the United States or do you have a valid appropriate permit to work in the United States issued by the U. S. Department of Justice of U. S. Department of Labor? *
  78. Are you applying for a sworn law enforcement position? (i.e.: correctional officer, etc.)*
  79. If yes, sworn law enforcement positions require applicants to be a U.S. citizens. Are you a U.S. citizen?
  80. Are you applying for a non-sworn civilian position? (i.e.: kitchen staff, etc.)*
  81. If yes, non-sworn civilian positions require applicants to either be a U.S. citizen, or have a valid permit to work in the U.S. issued by the Department of Justice of the U.S. Department of Labor. Are you a U.S Citizen?
  82. If not, do you have a valid permit?
  83. (Upon employment, proof of citizen status or work authorization will be required.)
  84. Financial Status
  85. Do you have any supplementary income other than your present salary?*
  86. Do you own or are you buying a home?*
  87. Do you rent?*
  88. Do you own an automobile?*
  89. Have you ever had an account placed in the hands of a collection agency?*
  90. Have you or your wife/husband ever had a lien, garnishment, or witholding order against your paycheck? (i.e.: unpaid debt, child support, etc.)*
  91. Have you or your wife/husband ever been sued for any reason?*
  92. Have you or your wife/husband ever filed bankruptcy?*
  93. Have you or your wife/husband ever been a party in a civil action?*
  94. If you are applying for a Correctional Officer position, and if married, does your spouse approve of you selecting a career as a Correctional Officer?*
  96. Certify*
  97. Revised 03/2017
  98. Leave This Blank: