Please fill out this questionnaire in its entirety.

HR Personal History Questionnaire

Please fill out this form to its entirety. If you have any questions, please contact HR at DCSOHR@co.delaware.oh.us.

Personal Information

Full Name:

Any Previous Names Used:

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthplace:

City/County/State/Country

Driver's License Number & State:

Driver's License Expiration:

Citizenship (Country):

Social Media

Email Addresses (List all used in the last two years):

Social Media Accounts:

Please provide links to account and all screen names.

Relatives

Mother's Name

First Last

Phone

Mother's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father's Name

First Last

Phone

Father's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Step-Mother's Name

First Last

(If applicable)

Phone

Step-Mother's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Step-Father's Name

First Last

Phone

(If applicable)

Step-Father's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse/Significant Other's Name

First Last

(If applicable)

Phone

Significant Other's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Marriage

Date of Divorce (If applicable)

Spouse/Significant Other's Name

First Last

(If applicable)

Phone

Significant Other's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Marriage

Date of Divorce (If applicable)

Siblings/Step-Siblings Name (If applicable)

First Last

Please provide any additional siblings, if more than three, at the bottom in additional information.

Phone

Sibling's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Siblings/Step-Siblings Name (If applicable)

First Last

Phone

Sibling's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Siblings/Step-Siblings Name (If applicable)

First Last

Phone

Sibling's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Children/Step-Children's Name (If applicable)

First Last

Please provide any additional children/step-children at the bottom in additional information, if more than three.

Child's Address (if different than your own)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender

Guardian (if not you)

Phone

Children/Step-Children's Name (If applicable)

First Last

Child's Address (if different than your own)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender

Guardian (if not you)

Phone

Children/Step-Children's Name (If applicable)

First Last

Child's Address (if different than your own)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender

Guardian (if not you)

Phone

Education

High School Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates of Attendance

Beginning Date

Dates of Attendance

End Date

Did you graduate?

Yes

GED

Post-Secondary Education (Please provide transcripts)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates of Attendance

Beginning Date

Dates of Attendance

End Date

Total Credits Earned:

Type of Degree Received:

Major:

Upload Transcripts

Max. file size: 500 MB.

Trade, Vocational, Business School, Law Enforcement Academy

Provide certificates received

Trade/Vocational/Business

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates of Attendance

Beginning Date

Dates of Attendance

End Date

Did you complete the course?

Yes

Type of school or training:

Certificate Upload:

Max. file size: 500 MB.

Educational Problems

Have you ever been placed on academic discipline, suspended or expelled from any high school, college/university, business or trade school?

Yes

If yes, describe in detail, starting with high school, list any and all disciplinary actions in any school or educational institution.

Include when the action(s) occurred, name of school(s), and explanation of circumstances.

Residences

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Moved In

Moved Out

Names of those you lived with:

Names of property manager or owner:

Manager Phone Number

Past Residences

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please provide prior residences for the past 10 years.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Housemates

Please list any roommates or anyone else you reside with. List their name, relationship to you, email, phone number, and current address (if different). Please provide any additional housemates at the bottom in additional information.

Housemate #1

Housemate #2

Housemate #3

Housemate #4

Housing Problems

Have you ever been evicted or asked to leave a residence?

Yes

Have you ever left a residence owing rent?

Yes

If you answered yes to either, explain (include when, where, and circumstances)

Employment

Include all jobs in the past 10 years (including military, internship, or volunteer work). Please provide any additional employment at the bottom in additional information, if more than three.

Current or Most Recent Employer

Name of Employer

Your Position:

Beginning Date

End Date (If applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor's Name

First Last

Phone

Name of Co-worker #1

First Last

Please provide the name of two co-workers.

Name of Co-worker #2

First Last

Reason for leaving:

Notice Given?

Yes

Ok to Contact Employer?

Yes

Previous Job #2

Name of Employer

Your Position:

Beginning Date

End Date (If applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor's Name

First Last

Phone

Name of Co-worker #1

First Last

Please provide the name of two co-workers.

Name of Co-worker #2

First Last

Reason for leaving:

Notice Given?

Yes

Ok to Contact Employer?

Yes

Previous Job #2

Name of Employer

Your Position:

Beginning Date

End Date (If applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor's Name

First Last

Phone

Name of Co-worker #1

First Last

Please provide the name of two co-workers.

Name of Co-worker #2

First Last

Reason for leaving:

Notice Given?

Yes

Ok to Contact Employer?

Yes

Issues in Experience and Employment

Have you ever received discipline at work? (This includes written warnings, formal letters of counseling, reprimands, suspensions, reductions in pay or title, reassignments or demotions).

If yes, explain where and the circumstances.

Have you ever been fired, released from probation, resigned in lieu of termination, or asked to resign from any place of employment?

If yes, explain where and the circumstances.

Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer?

If yes, explain where and the circumstances.

Have you ever quit without giving proper notice?

If yes, explain where and the circumstances.

Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.) by a co-worker, superior, subordinate, or customer?

If yes, explain where and the circumstances.

Have you ever been the subject of a written complaint at work, been counseled for lateness or absences, or received an unsatisfactory performance review?

If yes, explain where and the circumstances.

Please list additional siblings here.

Please list additional children/step-children here.

Additional space for any above sections with insufficient room:

Please add additional uploads here.

Max. file size: 500 MB.

Please add additional uploads here.

Max. file size: 500 MB.

References

Please list non-family, professional references. If you have previously provided reference, the same reference can be listed again here.

First Reference

First Name Last Name

Professional Title

Phone

How long have you known this person?

Previous Employer/Supervisor?

Yes

Second Reference

First Name Last Name

Professional Title

Phone

How long have you known this person?

Previous Employer/Supervisor?

Yes

Fourth Reference

First Name Last Name

Professional Title

Phone

How long have you known this person?

Previous Employer/Supervisor?

Yes

Third Reference

First Name Last Name

Professional Title

Phone

How long have you known this person?

Previous Employer/Supervisor?

Yes

If you have any questions please contact DCSOHR@co.delaware.oh.us or call 740-833-2867.

Employee Personal History Questionnaire

Please fill out this questionnaire in its entirety.

HR Personal History Questionnaire

Personal Information

Social Media

Relatives

Education

Trade, Vocational, Business School, Law Enforcement Academy

Educational Problems

Residences

Housemates

Housing Problems

Employment

Issues in Experience and Employment

References