Background History Disclosure Statement

Please complete the form below

Full Name

First Name

Last Name

Alias or Nicknames Used

Date of Birth

YYYY

Place of Birth (State if US, Country if no US)

Social Security Number (last 4 #)

Texas Driver License Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Workplace

Profession

Do you have prior law enforcement or military work history?

Law Enforcement

Military

Are you a member of or have you been associated with those who are members of any organization that advocates the overthrow of the U.S. government or any government entity in the U.S. by force or violence?

Do you understand that a thorough background investigation will be conducted on you prior to acceptance into the BCPD Citizen’s Police Academy?

Have you ever been arrested?

If "Yes" please explain circumstances, dates, charge title, arresting agency, etc.