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PERSONAL HISTORY QUESTIONNAIRE FOR POLICE DEPARTMENT USE ONLY PALM BEACH HUMAN RESOURCES DEPARTMENT 360 SOUTH COUNTY ROAD PALM BEACH, FLORIDA 33480 (561) 838-5450 posmionappLepror: Police Trainee CONFIDENTIAL, ‘LAST NAME FIRST MAME ~ | MIDDLE NAME ~ Mastanatlo Poberk Edward ae ARS ecu iP CODE [la a FIORE (886) Fo -2377 TERS Se ME MAZBle T6S> BN YU Sek Wale BY Femsle C] -MARTALSTATUS: Single BJ_Manied [1 Ohoreed [widowed (1 RACILIDENTRIGATION: White fl Htparle []_amercaniodin [Block [I AslanPacic ister 1 eve you ered nthe Armd Fon cee nO ft Na Kyeswhenddyousca? — From _ 0% 1260@ tw 0% [201 aor Flic Fores. rare _€ 5 Do you csi veoran'sProfrenes (Chapa 296 lita Sats) Yee NO {tye youre dues ementcopy af éncumedain of your ves refers sas) ve you chimed Veta Profrence ine Ocber 187%.- - Yes BHO ‘CONTINUED ON NEXT PAGE Seyret + OONTINUED FROM PREVIOUS PAGE: Lolert € Wasbrange|o am eligible to partfefpate ‘Print your name) In dhe testing procass for Poiica Offcar for tha Town of Palm Beach Police Department bocausa: (REQUIRED) Lama Florida stato ar outot-tate cortifad Pollca Officer or have successfully campletad the Florida Basic Recruitment Training Program and have either passed or am eliginle to take tho Stata Officer Gartficalton Exam I possess an AA degree, AS degree, or at least 60 credits from a regionally accredited collegefuniversity. The degree must Include basic general education caurse raqufemonts. Prior exparianceas a Polca Oficerandiara BA, BS dagree or 120 clioge credit hours are preferred. (amc ANY OF THE FOLLOMINS THRE APPLY) 4 Shave completed a Florida Department of Law Enforcement approved Basic Recruit Academy; Current skdsbending, Acoetrny | nave passed the Florida Law Enforcement Officer Examination; Lam eligible to take the Florida Law Enforcemont Officer Examination; {possess oram afiglbie for Florida Law Enforcement Certification; Vil rt ‘Blgnature of Appl IFYOU DO NOT MEET THE REQUIRED EDUCATION CRITERIA, AS LISTED ABOVE, YOU ARE NOT ELIGIBLE TO PARTICIPATE IN THIS PROCESS. NOTICI “please read and follow these instructions for compltion of tha Porsonal History ‘Awestionnalre. Your ahility to complete this dacument a¢ requested will ba pvaluatad and used as one basis for employment decisions. This document, when completed, will be used by the Palm Beach Police Department as 2n investigative ald. Retention ofthis porsonal slate win! remain In the Investigative files of the Human Resources Department for ane jenn Exarnplas of tha types of Infonntion thatwil i collected tn conducting a background investigation Include: employinent and education historias; mitary, cred and fancial information; motor vehicle and polos records; and information about your abies, family, character, festyl, antl organization ‘nvambarahles. (Madical and heallh related lestas wll ko rovkawed post-employment off). Iefermation wiflba obtained by beta, felophona, and porsonal interviews with both primary and secondary sources, This Infonnalon wil he used as ona basis for employment decisions, sTRUCTIONS: 44 Hand prin clay, blackInkand in your own handing. 2 Awer every question. i a question does not apply to you, so state with NIA (Not Applicable}. Any unanswered, ncornplota,or amntied quastions may resultin ejection of your application or alemlssal 4, tthe space availabe is insufficient, use saparate chest of 8 472x 11 paper and preceade each answer with the number of the referenced block, 5. Statements mada hareln ara subjectto variation to determina your qualifications far employment. Misetatements ar omissfons are cause for rejection or dismissal. 8 Angwerall questions accucately and completly: Da not make exaggerated, false, ormleleadng statements, as thay may catise your rejection or dismissal. 7. Each and every question has 2 purpose, so donot ilo answer any question completely, evan Ifyou. feel itis "not important.” Read and ston below: "have raadand | understand al oftha abova instructions, | also undorstand that | may ba asked to take a ‘voice stresa la detactor) examination to detenrine the authonticy of the Information provided inthis ‘questionnaire. ihe the “All other signatures on this Personal History Queationnatro must be property notarized. TURNTONEXTPAGE =» CONTINUED FROM PREVIOUS PAGE ‘This application MUST be accompanied by the following documents (those appl ubmiasion, This documentation: investigative aid. ble) upon iN be used hy he Palm Beach Pofics Dopartment as an you do not have the following appropriate cerlffed documentation and must request that it he sentta you, yu may subynét your appliction packet to the Town of Palm Baach by noling that you have requasted ‘certified copies. Your application pocket must be suberited olthor withthe appropriate certified: documentation or the notation tht the documentation has bean raquested andwill be provided as soon as possible. ‘Attached OR Date Requested ‘L CERTIFED COPY" of Bith Cortfeate, 2. CERTIFIED COPY" of Maniage Cortificat, it applicable, iat ry 3. CERTIFIED GOPY*of Legal Name Chango Papars,appicable, ia 4 CERTIFIED COPY" of Separation or Dlvotea Papers, appicable. ia pin 4 CERTIRED COPY: of igh School Transcripts or GED Certiica. g 6. CERTIFIED COPY" of Cllege Transcripts with Official Sea, fappfcable. Ee *CERTIFIED COPY inthe above instanoss means tha the documeni(s) must be cortified by the orfalnating ‘agency, Ifyou do nat havetha necessary ceriiad document, you must eontact the originating agenoy and ask fr's ‘ered copy. This mal than ba sant othe Town of Palm Beach Humen Resauroas Dspartment For exemple, 6 ceriied copy of High Schoo! tanecrinls would requ that you contact the appropriate High School and request them o senda oeetfied copy of your ranserias fo you or the Tann of Pain Beach Hursan Resources Department. ‘Aphotocopy of your ulplona ce transcripts does nat meet he certified qualication. Your original copy ofthe diploma ‘aso does net meet tls quaffcation. In adettion ta the abave, this application must be accompanied by copies of the following documents (iF applesble) upon submiselon (Pfease chock the angrpriae heves 40 mdiosla those documents you sce subiting}: FG Serene ae 8 Copy of Social Securty Cart F] © hel Netraaion Catia, ¥ appt fet posters cry Q 1. Allen Werk Permit (Green Card), it appicabla (ron-oertiad pasiions only) Bl 1. Gopyer boa try sche Popa, Wapplesble UO 2 |f Florida Stale Certiiad Potiea Officer, capy of certificate: C) Rotors Gere Poles Oncer- otal PotveAraeny Tensotet Oo 4 ‘Coplas of any Specialized or Advanced Trairing Certiicaies, Le., CPR, First Aid, FOC Leone, Pte Leense 6 oO ‘Copy of Passport (page 1), il applica. PERSONAL HISTORY QUESTIONNAIRE “roan rere wooleWE age Mosrrangely _ Coloer Eduard SAR a ln aa a RE an RT| — BATCOF ORTH “Nl may i a i a oo pe Al mie ula NAR a ‘wig | Shas Sa a as EE 1 o ZN [iepeeers eoey on epee wee? ice oR ly, County, Sas) — Tht copy of Et eal) Earmdan Corn dun New Sarsey, eae arate teeeeaeecg Ton pe steeorgl traces = = zi _ ae Woes Camm Semmes ann Coens ‘ai eter ear Se a N [A _ [ Teradata penis = SS TOR STE wa a 1 fav mannan odorata iw tahtaattemaion —N [Bp Sore | marae oun” | ae Go tet rea 7 = SeRgnEe ane mone = : * tained nano ea om miooet a fon Sar aT, Wyse Gand Tes Freebie Hapaemttnst Teta ether — Apa ELogi ba 1B Antoun eaten ony dpa ocean mE wo ‘Gar apr ha ana boson fe copy e Sopmri et Ranier waans nth, aaa one _ ORES reusionsne | TRE Nie - 1, stint er gin sag rb ct, undone Harrtee ptintn bert en rgd INCLUDE AI OTIC PERSUAS YOU HAVE RESIOEO WT CORA WHOA A RELATIONSHIP EensraD OF XEN, Fy OE PRIEND, PEATE Tae | a TRESS any” —[— pene [mere | — ena — Tame poverty TR I fhe unl 26 Te ae Fla OTRO "841 98ie] aii TTA ET { iz HMR atogila [MOTIDEbIm dedinn Pi, [!S19R rons yet TEN yas ogra wea Ut naar 2d me amb of pt an ee, op ram: gmontvear|_—_ 0% | bo reximornyein PERS ey oon 2 == Soe a TE i an anand Home: Spee eg to: LE From unripe OTS Font ty, Sry EP Ses Lantiowtatise Karan, Pei gla femal: fe S lawucesuwen PERE, GEZO su. BCL ~ oy __VAAE South weal Contes aun E Dae EE From: jnontiyers__ O44 E - an = ead eee MOR C ee a Sa From: (monthiyean Die [1% cay Lanclonts Name: une a: PETS Landlord's Address: ink sige vA. From (wonton) OB | {2 uae Agaroc a ‘Count London's Name unk Ema, Landlord's Address: UAE cr Une on From: (monthiyeoe) ro: monenivnors OF)'| 12 own. Ram _2¢ ut ae gitthsaecnpeo ts Phone Ho. om Count tae: 70 Lanatord's Name: wu on Ema: ene Landon’ Ader: lye ink sate; A ap: UE Frome foathiyerr) 98/08 to: eo ce ity County Site: i 2 Landlord's Maro: i a ta Ematt: nk Landlord's fitdrwse_ iA IE ome Bielson AEB st: Ee FFIOL Frome onthiven) 07/42. tesimontayen) 92/08 own XC rt___ a Phone No. ag a, aaa. so P cméore vane Earnl ly be pence, Landlorte Addrass: inveors OB/ 1) iy IB. se. fg a: VIA srameimentvees A) | Fe o: gmoney on est, tet Aas Phone ou comin Bat = Lands Nant ema toons Ass _ ome Sua, me Uta element rior igh, a igh shoal tenet nude copy athigh school or GED dons) LocaTiOn SL iW) Faciclaning oa Maple chad 05/49 | 0/96 [aa wir [eswcrlmaie rd tags trade wr 04/26 elas | a | Mao ahaaltline cadrive st Maple shade yt (09/1 |06/o' x ius uintto Orlran NT onors [64 /eF [o6/o7 | 2 [72 W4 | GER Wanpieabay " Figaro lo oT cage a TTS aan ie ST SREP aT RSF THAT TURE AD COORTION OF COLLEGE [DATES ATTENDED, EDIT HOURS DEGREE] Year ‘OR UVERSITY FROW [To | SSWESTER | cUARTER |] er | pecewven [o-3)0g [23 [ tw ae Ph | vin | afer ois folio Ia Tn | ada Jolt lPresent] wid | wig | ay SA NT DST moe ga ao me SERTFIORTE FRR | To] _ tase oF scH004 mo LOCATION coursesoupe yee Byles [oft [Aue Zora Com bet Rewenition (Pembat Arimrnition, Big THY Ais pron. Ada jobool! [Leadership Manasemerl| SJoe |oBfoe [Eechaica| training. |Buplesives handli ‘Ware jou sar mpl aranpaad Ham RNY SCHOOL or wr ¥oD oer BSI Hyon ao ORGAT? Yes WoT perenne saved ion in htahachoe | PR ered detenies 4nd int Baral = “EGRESS rego gangs yur on sah aon aE anpene Sm, FAG i unoersTanomG en wavounse ERE] 06D: [PIC [BE] ea00 FAR Eve. | 8000 | FART] EXC | OOD: [FAR nT | Inst typeof spec Nene mache pet ns opt ee cng leenag suey, whore exncow at 6108, Sete ateCvontlenea ores veep hii peru rhewn) Include ops ne spss tyurossssandnoctexsantecgetyacni. Fr ram te von aces eongeheypnc, 8 17, SPECI CUALEYATON OSHS cont 2 Beprodmstenaaber a wont por mln: rena AO 14 ksesgehtqaitsinesnctemordnaplsion Forasephfirmnpat pubs retacen e nieroue t ar nats Rol mae tata pone desndennond lesb ete ows yu evar sven ality ona! expan of he Unie Stas, etsing TE? Yes WoT ie amntszo oe DO Ny ier Ptr toaccemmnctonns Bie Force 4 Wea typeotatecptny cen atmuagsial ouineseivice? Yep BF 0 "ype previa dat, ecladag ot, pone, nat of tne ond ate ke _ yo yu serosa uml fa rarhodto mal by ance athe youd any nna akan eget youn Saterpoimantorpooton you voriaa? Yee CNG ‘ree gingrameandaainestemion, grnintecie amdoncsinenbeae, ay | 1 Doyen cuectiomeadana stom? vee] te boy anit teeming niamet Yer C1 te DF A Numyoutedipeiece iti ahitwen? Yes to if + 9. Homey retour smite sn nica foremzamal ra i Gra Pes Dopo ha ou me spa pro Fterunpaltenrcs fort enornmort gure shal lt ibe blow eb an Galea? Yee oS ry anata cele /iie| West Valin Gea. | ahi ti ON Yon Readiy 3th Midmi Dace Yor BE No City ote oats sow 8 oyouce nave yc aanadary tot orth nym, peso cerprei cetng way ar pani WAN es och Bamngaet Nee EY Ne oye orharo youve eyed abuses, or youor hava you chr bon a pase rena oer Inary uns or organ nek Nbnraeacarontertrmarempoyer? Tee C] Nop Fyee Brome nr ad eres of ent or poston boo sa maPLoMeNT, count 1 reeyosnomorhaveyou vere sted 1a, revi domain ate Fea iit oermasinatuchessarmetezin? Yes 1 Ho ik fad tenet ecb ea fo sts ste oe abs a Seemaeni etre Yao WO meet i fiemelnlantagoutne ch Pei ies ere, Facer netnemRERST, fares ‘dtr tte NEL PaCDS OF DE HILARY CERISE HPROPER: Sch AND ALO. ‘enporryaeeonal, a elton be yeu wera etteryeyed provide ete ox nt Ui omaest Uae FRON DATE NRE OF ENPLOVE™ Salle | Unemployed aetna pose, a wl4a [PHONE NO. ee Coa ovltte fiw SR | EAP Or EDFA OPE EI sla] wia “HORRVEND WHY YOU ENET ID | Separded From AMM NAIEOF CO WORE Mh citar TRE DATE ROE DF EHPCOVER luniied Slates Hie Forse ARTE Cy cee Bk procrormrens niet Serpetn 031Ib [30600 Ammo Way 78 4iS WMHbz TW STATE BP code Bac ersieact Pl 2303s IUAIEOFSTPERTSCR SuPeRMeons Fa Sue Varmuzal unt. i eZe lsepedoded trom fAifitact Hrdonte Me Queen Supa Terel Manage daily Munitions operadtons wOlor. 01 |Lvcns _Grelrolet POET TRE od paste PeoF Man 2108 |lb27 IS->% incited of 4g) eZ. BNZo¢lomurtgn 1S OBC4R, ane oF SUPERUSOR — SOPERSORS ERAT ure, “SERRYERO WY oO, YOULPAVET 20k. | MiNi ar ert Peohieles BROW DATE foe OF ce 407 | Davi Cevlou ee 7 STREET ADDRESS TRNISK Mor ed NS__ 0087 ‘SAAR fa fo" OC ET {g\& pent z Dat Getle vane Mig osteo ___Casaared Const wok on labor.