Background Questionnaire

Read and answer the following questions carefully and honestly.

Answers are subject to verification by a Polygraph Examination.

Have you ever committed any of the following acts during your life whether it came to the attention of authorities or not?

EXPLAIN ALL “YES” answers on the following blank page provided.

  • Spousal abuse (including common-law)
    • Yes
    • No
  • Any violent assault upon another
    • Yes
    • No
  • Forgery
    • Yes
    • No
  • Homicide
    • Yes
    • No
  • Robbery (theft from another person utilizing a weapon of force)
    • Yes
    • No
  • Burglary
    • Yes
    • No
  • Kidnapping
    • Yes
    • No
  • Arson (intentionally set fire)
    • Yes
    • No
  • Extortion (blackmail)
    • Yes
    • No
  • Embezzlement (theft of money)
    • Yes
    • No
  • Rape (sexual intercourse by force or against the wishes of another)
    • Yes
    • No
  • Child Abuse
    • Yes
    • No
  • Child Molestation (any sex act with a child)
    • Yes
    • No
  • Prostitution (sexual acts for money or other considerations)
    • Yes
    • No
  • Soliciting Prostitution (asking for sex in return for money or vice versa)
    • Yes
    • No
  • Theft (including shoplifting)
    • Yes
    • No
  • Convicted of a DUI or charge reduced to reckless driving
    • Yes
    • No
  • Have you in the past or do you now regularly associate with persons
     whom you know to have engaged in and/or been arrested for unlawful
    possession or use of any illegal substance?

    • Yes
    • No
  • Have you ever been arrested for an illegal sex act?
    • Yes
    • No
  • Ever charged with a crime not mentioned above?
    • Yes
    • No

Explain all “Yes” answers to the above questions in the spaces below.

List the question # and then describe the incident.

Be thorough with your explanation, use dates where appropriate.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

 Employment

  • Have you ever been terminated or asked to resign from employment?
    • Yes
    • No
  • Have you ever taken any property from an employer?
    • Yes
    • No
  • Have you in any way falsified your employment application or made
    any misleading statements?

    • Yes
    • No
  • Have you ever made any false or misleading statements or omissions
    to any employer or potential employer?

    • Yes
    • No
  • Have you ever made any false or misleading statements or omissions
    to any employer or potential employer?

    • Yes
    • No

Explain “Yes” answers in detail below. List the question # and then thoroughly explain.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Financial

  • Do you feel that you now have a good credit rating?
    (Yes answer does not need explanation)

    • Yes
    • No
  • Do you have any bills that are currently passed due?
    • Yes
    • No
  • Have you filed for bankruptcy within the past two years?
    • Yes
    • No
  • Have you ever failed to file an income tax return?
    • Yes
    • No
  • Have you had a bill turned over to collections within the past two years?
    • Yes
    • No

Explain all “Yes” answers to the above questions in the spaces below.


List the question # and describe the incident. Be thorough with your explanation, use dates where appropriate.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

General

  • During the oral interview, did you answer any questions untruthfully?
    • Yes
    • No
  • Are you presently driving without auto insurance?
    • Yes
    • No
  • Have you ever filed a fraudulent insurance claim?
    • Yes
    • No
  • How many traffic citations have you received within the past five years?
    • Yes
    • No
  • Have you ever taken a Polygraph Examination?
    When ___________Where ______________Result _______________

    • Yes
    • No
  • Have you ever been present when someone else committed a criminal act?
    • Yes
    • No
  • Have you ever purchased or sold any property that you believe may be stolen?
    • Yes
    • No

Explain all “Yes” answers to the above questions in the spaces below.

List the question # and then describe the incident. Be thorough with your explanation, use dates where appropriate.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

  • Have you used marijuana?
    • Yes
    • No

Last time: Month/Year ___________First time: Month/Year ______________________

  • Have you ever misused a prescription drug?
  • Within the past year, have you been in the presence of anyone using illegal drugs?
  • Have you ever purchased, sold, or supplied any illegal narcotic, Steroid, marijuana, pill or drug?
  • Have you ever been the middleman, go between, or “done a favor for a friend”, in regards to becoming involved in a drug transaction?

 

  • Have you ever used or experimented with:
  • Cocaine – Yes / No
  • Heroin – Yes / No
  • LSD (acid) – Yes / No
  • PCP (angel dust) – Yes / No
  • Mushroom, mescaline or any hallucinogen – Yes / No
  • Hashish – Yes / No
  • Crank, Methamphetamine – Yes / No
  • Speed or Crystal Meth – Yes / No
  • Uppers/Downers or Barbiturates – Yes / No
  • Steroids – Yes / No
  • Ecstasy – Yes / No
  • Any type of “designer drugs” – Yes / No
  • Any other drug besides marijuana – Yes / No

If you answered “Yes” to any of the above drug usage questions, complete the section below:
Drug _________________ First Time_________________ Last Time____________________
Drug _________________ First Time_________________ Last Time____________________
Drug _________________ First Time_________________ Last Time____________________
Drug _________________ First Time_________________ Last Time____________________
Drug _________________ First Time_________________ Last Time____________________
Drug _________________ First Time_________________ Last Time____________________

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