CITY OF MILWAUKEE FIRE AND POLICE COMMISSION
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)CITY OF MILWAUKEE FIRE AND POLICE COMMISSIONPERSONAL HISTORY QUESTIONNAIRE – FIRE CADET (2019)The Personal History Questionnaire (PHQ) is one part of the background investigation process for the position of Fire Cadet.You are required to complete a PHQ form and return it to the City of Milwaukee Fire and Police Commission (FPC) on orbefore Friday, April 26, 2019 at 4:30 p.m. If you fail to complete the PHQ, or it is not received by the deadline, you may bedisqualified from further participation and no longer considered for the position.Questions about completing the PHQ may be directed to the FPC at 414-286-5068 or 414-286-5071. Follow these instructionsto complete your PHQ: The PHQ must be completed directly by the individual who has applied for the position. Responses may be typed or, if you complete the PHQ by hand, must be legible and printed using black ink. Leave no response blank. If the question does not apply, indicate “N/A” (Not Applicable). Ensure all information provided is accurate, complete and truthful:o Falsification, willful misrepresentation, or intentional omission of material information will result indisqualification and/or termination of employment by the Milwaukee Fire Department.o Failure to include complete information may result in disqualification because it may be considereduntruthfulness. Therefore, you should take necessary action to obtain all informationo If you are unsure of an exact date or have other partial information, include as much information as possible(e.g., month and year or approximate year, etc.). Do not leave the response blank, as that may also beconsidered untruthfulness, resulting in disqualification. If there is a change in any information (name, address, phone number(s), employment, driving record, etc.) that occursafter submitting your PHQ, it must be reported to the FPC within five (5) days of the date the change occurred. Contactthe FPC at 414-286-5068 or 414-286-5071. If you need additional space for your response, write your response on a separate sheet of paper and attach it to thePHQ. When you return your PHQ, the documents listed in the Document Checklist (see next pages) must be attached. Your completed PHQ must be received by the FPC by Friday, April 26, 2019 at 4:30 p.m. You may deliver thedocument personally, have someone else drop it off for your, or mail it. Whichever method you choose, yourcompleted PHQ must be received in our office or postmarked by the deadline date. The FPC is located in City HallRoom 706-A, 200 E. Wells Street, Milwaukee WI 53202. If your PHQ is not received, or postmarked, by the deadline,you may be disqualified. IMPORTANT: When you submit your PHQ, the document must have your fingerprint on it. Therefore, you mustschedule an appointment with the MPD to be fingerprinted prior to the PHQ deadline. You do not have to have yourPHQ completed when you get fingerprinted, but bring along your PHQ so that you can add your fingerprint toit.o You should schedule your fingerprinting by calling (414) 935-7388 between 8:00am – 5:30pm, Monday Friday. Fingerprinting is done in the Police Administration Building, located at 951 N James Lovell St (7th &State Streets), Room 601, Forensics Section. Appointments are available between 8:00am and 5:30pm andmay be available the same day. You must take your PHQ and a government-issued photo I.D. when you go toyour appointment. Because appointment times may fill up quickly, you are encouraged to call to scheduleyour appointment as soon as you receive this letter. If you omit this step, you may be disqualified, or yourbackground investigation may be delayed.Page 1 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)Document ChecklistSubmit all the following documents in order for your background investigation to begin. Attach copies of the documentslisted below that apply to you. Failure to attach copies of all required documents when you submit your PHQ may resultin a delay in completion of your background investigation and, in turn, may affect your ability to be hired in order of rankon the eligibility list.You are to submit photocopies of documents 3, 4, and 5. The photocopied documents you submit will not be automaticallyreturned to you. You may request documents be returned during your initial interview with the FPC.Document 1: Legal Birth Certificate (Hospital notices are not acceptable) NO PHOTO COPIES * Wisconsin law 69.24strictly prohibits copying vital records; therefore you must submit a true certified copy of this documentDocument 2: One (1) Recent Individual Passport-Sized (2”x 2”) Photograph.This photo should NOT be a casual snapshot taken with your phone. You can go to many locations (for example,Walgreens, CVS, Walmart, etc.) and have a passport photo taken and printed. You are not required to have apassport, only a printed photograph in the same format as that used for a passport.General requirements: Your head must face the camera directly with full face in view. You must have a neutral facial expression or a natural smile, with both eyes open. Taken in clothing normally worn on a daily basis Taken in the last 6 months Use a plain white or off-white background Be sized correctly at 2 x 2 inches (51 x 51 mm) Head must be between 1 - 1 3/8 inches (25 - 35 mm) from the bottom of the chin to the top of the head Printed on matte or glossy photo quality paper Printed in color You cannot wear glasses. You cannot wear a hat or head covering. You cannot wear headphones or wireless hands-free devices. Fully detailed specifications and examples can be found sh/passports/photos/photo-examples.html.Document 3: A photocopy of a government-issued photo ID (Driver’s License, State ID, Military ID, Passport).** For Out of State Driver’s License holders, please attach an Abstract of your driving record. You canobtain an Abstract with the Department of Motor Vehicle (DMV) of your home state.Document 4: A photocopy of your Social Security Card – showing your current legal name.Document 5: A photocopy of your official transcripts verifying your enrollment in or graduation from an accredited highschool, high school equivalency program which conforms to the standards established by the State of Wisconsinfor high school equivalency, or a home school program in Wisconsin which meets the requirements of theDepartment of Education.Page 2 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)Other documents that may be necessary:If you have served in the military, you must provide: DD-214 Military Form (undeleted copy) – undeleted includes the bottom portion of the form which shows thetype of discharge and character of service.If you were required to register for Selective Service and have not served in the military, you must provide: Selective Service RegistrationNote: Print a copy at http://www.sss.gov/records.htm or call 847-688-6888.If you were not born in the United States, you must provide: Naturalization papersIf you have legally used any other name, you must provide: Documents pertaining to name change (e.g., marriage, divorce, adoption, or other legal name change)If you are unable to obtain a copy of all required documents before the deadline, submit the completed PHQ on time andattach a written explanation of which document(s) are missing and when you expect to be able to provide them. Submitthe missing documents as soon as you can.Page 3 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)Section 1 – PERSONAL INFORMATION1. Legal Name:Last NameFirst NameFull Middle Name2. List all other names you have used or been known by (nicknames, maiden name, etc.) and explain each one:3. Current Social Security Number (000-00-0000):4. Other Social Security Number(s) that have been assigned to you:5. Date of Birth:MM6. Gender: Male/ DD/ YYYY Female7. Age at last birthday:years8. Place of Birth : City:County:State:9. If place of birth is other than Milwaukee, when did you move to Milwaukee?MonthYear10. Present Address:City:State:11. Home Telephone Number: ()Mobile Telephone Number: (Work Telephone Number: (-))-Zip:Hours available at this number:Hours available at this number:Hours available at this number:Email Address:Page 4 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)NOTE: Marital and parental status is being elicited only for the purpose of conducting a background investigation.Marital and parental status are not used to determine your suitability as a Milwaukee Police Department employee.12. Current Marital Status: Never Married Married Divorced Separated WidowedName of Present Spouse:Last NameFirst NameMiddle NameFirst NameMiddle NameSpouse’s Other/Maiden Name:Last NameCity / State Marriage Performed:Date://Present Address (if different than yours):City:State:Spouse’s Telephone Number: ()Zip:Spouse’s Employer:Occupation of Spouse:Spouse’s Business Address:Business Phone: ()-13. Name of Girlfriend / :Boyfriend / FiancéeLast NameFirst NameMiddle NamePresent Address:City:State:Telephone Number: ()-Zip:Date of Birth:Occupation://Employer:Business Address:Business Phone: ()-14. List all previous marriages in order of occurrence:Name of Former Spouse:Last NameFirst NameMiddle NamePresent Address:City / State Marriage Performed:Date://Court Issuing Divorce / Annulment: :Date Filed://Date Granted://NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATPage 5 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)15. List all children (Include natural, stepchildren, adopted children, foster children and other dependents). Ifdeceased, so indicate.a. Name:Last NameFirst NameMiddle NamePresent Address (if different than yours):City:State:Zip:Your relationship to the child:Name of other parent:Last NameFirst NamePhone number of other parent: ()-Middle Name-b. Name:Last NameFirst NameMiddle NamePresent Address (if different than yours):City:State:Zip:Your relationship to the child:Name of other parent:Last NameFirst NamePhone number of other parent: ()-Middle Name-NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATSection 1A – RELATIVES, FAMILY MEMBERS & LEGAL GUARDIANS16. Supply the appropriate information in the spaces provided below. If a category is not applicable write “n/a”and if the information is unknown write “unknown” (but please provide as much information as possible).Indicate if the person is deceased.a. Father:Last NamePhone number: (First Name)Middle Name-Address:CityStateZipb. Mother:Last NamePhone number: (First Name)Middle Name-Address:Page 6 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)CityStateZipc. Step-Father:Last NamePhone number: ()First NameMiddle Name-Address:CityStateZipd. Step-Mother:Last NamePhone number: ()First NameMiddle Name-Address:CityStateZipe. Father-in-Law:Last NamePhone number: ()First NameMiddle Name-Address:Cityf.StateZipMother-in-Law:Last NamePhone number: ()First NameMiddle Name-Address:CityStateZipg. Legal Guardian:Last NamePhone number: ()First NameMiddle Name-Address:CityStateZiph. Legal Guardian:Last NamePhone number: ()First NameMiddle Name-Address:CityStateZip17. For the following, check the appropriate relationship:a. Brother Step-Brother Half-Brother Sister Step-Sister Half-SisterName:Phone Number: (Last NameFirst Name)-Middle NameAddress:Cityb.StateZip Brother Step-Brother Half-Brother Sister Step-Sister Half-SisterName:Phone Number: (Last NameFirst Name)-Middle NameAddress:Page 7 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)Cityc.StateZip Brother Step-Brother Half-Brother Sister Step-Sister Half-SisterName:Phone Number: (Last NameFirst Name)-Middle NameAddress:Cityd.StateZip Brother Step-Brother Half-Brother Sister Step-Sister Half-SisterName:Phone Number: (Last NameFirst Name)-Middle NameAddress:CityStateZipNOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATSection 2 – RESIDENCES18. Have you ever lived in a foster home? Yes NoIf yes, explain and give details (Names, Dates, Addresses, etc.)19. List below, from most recent to least, each place you have resided in in the last seven (7) years. Be careful togive your correct addresses (for instance, do not simply write “12th & State St.”, write the actual correctmailing address). Do not omit any addresses. Periods of residency at a college may be denoted by the collegeaddress, although specific addresses are preferred. Provide as much information as possible.Present Address:CityStateZipWith whom do you live?From (Month/Year):/To (Month/Year):/Do you Rent OwnIf you (not your parents) were the person renting, please provide:Landlord Name:Landlord Phone: ()-Previous Address:CityStateZipWith whom do you live?From (Month/Year):/To (Month/Year):/Do you Rent OwnIf you (not your parents) were the person renting, please provide:Landlord Name:Landlord Phone: ()Page 8 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)Previous Address:CityStateZipWith whom do you live?From (Month/Year):/To (Month/Year):/Do you Rent OwnIf you (not your parents) were the person renting, please provide:Landlord Name:Landlord Phone: ()-Previous Address:CityStateZipWith whom do you live?From (Month/Year):/To (Month/Year):/Do you Rent OwnIf you (not your parents) were the person renting, please provide:Landlord Name:Landlord Phone: ()-NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMAT20. List any other city or cities you have ever lived in. (Include Military)21. Has a formal eviction action ever been commenced against you? (Note: this question is in regards to youyourself, not your parents or legal guardian) Yes NoIf yes, explain and give details including date and County:Section 3 – CITIZENSHIP22. Are you a United States Citizen? Yes No23. If you are of foreign birth, or are a naturalized citizen, please provide the following:County of BirthDate of Entry into the United StatesMM / DD / YYYYPort / Place of Departure for the United States:Port / Place of Entry into the United States:Page 9 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)If you are a naturalized citizen, provide the name and address of the person who sponsored you on arrival:Sponsor Name:Last NameFirst NameMiddle NameCurrent address of Sponsor:CityStateZip CodeYour first address after arrival in the United States:CityStateZip Code24. When did you obtain citizenship?Petition NumberDateMM / DD / YYYYStateCourtCertificate NumberSection 4 – EMPLOYMENT HISTORY25. Beginning with your current employment, list all jobs you have ever held including full-time, part-time, andtemporary positions. If you have had intervening periods of military service, unemployment or publicassistance, list those periods in sequence in the spaces provided.SAMPLE RESPONSE:Dates of Employment: From:To:Employer:09 / 199911 / 1999Month / YearMonth / YearrdAddress: 2323 S 23 St., suite 233Position: Insurance AgentSupervisor: Mr. Frank FranklinCover-All InsuranceMilwaukeeWI53233CityStateZipPhone: (414) 233 - 3333Co-worker name: Thomas JonesCo-worker address: 1717 S 17th St. Milwaukee, WI 53217Co-worker phone: (414) 217-1717Reason for Leaving: Company went out of businessPage 10 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)a. Current EmployerDates of Employment: From:To:Month / YearEmployer:Month / YearAddress:CityPosition:Supervisor:Co-worker name:Co-worker phone: (StatePhone: (Zip)-Co-worker address:)-Reason for Leaving:b. Previous EmployerDates of Employment: From:To:Month / YearEmployer:Month / YearAddress:CityPosition:Supervisor:Co-worker name:Co-worker phone: (StatePhone: (Zip)-Co-worker address:)-Reason for Leaving:c. Previous EmployerDates of Employment: From:To:Month / YearEmployer:Month / YearAddress:CityPosition:Supervisor:Co-worker name:Co-worker phone: (StatePhone: (Zip)-Co-worker address:)-Reason for Leaving:Page 11 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)d. Previous EmployerDates of Employment: From:To:Month / YearEmployer:Month / YearAddress:CityPosition:Supervisor:Co-worker name:StateZipPhone: ()-Co-worker address:Co-worker phone: ()-Reason for Leaving:NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMAT26. Have you ever received unemployment compensation in the past five (5) years? YesIf yes, specify dates below:From://To://From://To://From://To:// NoNOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMAT27. Have you had any extended work absences for reasons other than medical/sick leave or earned vacation? Yes NoIf yes, explain and give details (including dates) of all instances:28. In the last five (5) years, has any employer ever advised you of any problems, or have you had any problems,such as poor attendance, tardiness, difficulty getting along with supervisors or co‐workers, and/or being belowrequired standards for quantity and/or quality of work? Yes NoIf yes, explain and give details of all instances (e.g., employer, dates, circumstances, your name attime of employment if different from current name):Page 12 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)29. Have you ever resigned in lieu of termination (fired) or been terminated, disciplined, reprimanded, orsuspended at any place of employment? Yes NoIf yes, explain and give details of all instances (e.g., employer, dates, circumstances, your name attime of employment if different from current name):Section 5 – MILITARY SERVICE30. Have you registered with the Selective Service (Under the Selective Service Act: Section 6, 50 U.S.C.APP456) in accordance with federal law governing males who have reached their eighteenth (18th) birthday? Yes No If no, explain:31. Have you ever served in the Armed Forces, National Guard or Military Reserves? Yes NoIf no, skip to question 45 (Section 6).If yes, continue this section.32. List active duty and/or reserve duty assignments:Branch:From:To:MM / DD / YYYYBranch:From:MM / DD / YYYYTo:MM / DD / YYYYBranch:From:MM / DD / YYYYTo:MM / DD / YYYYMM / DD / YYYY33. Name, address and phone numbers of unit(s):Name:Phone: ()-Address:CityName:StatePhone: ()Zip-Address:CityStateZipPage 13 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)34. Type of Separation:Character of Service:Narrative Reason for Separation:If character of service is other than “honorable”, explain:35. Where stationed for Basic Training?Near what major city?36. Where transferred after Basic Training?37. Have you ever served outside of the United States for any period(s) of time? Yes NoIf yes, explain and give details (including country(s), dates, etc.) of all instances:38. Were you ever convicted by a court martial? Yes NoIf yes, explain and give details (including dates, incident, punishment, and/or disposition, etc.) of all instances:39. Have you ever been the subject of any other judicial or non-judicial disciplinary action while in the military? Yes NoIf yes, explain and give details (including dates, incident, punishment, and/or disposition) of all instances:40. Discharged fromwhere:41. Rank at time of discharge:Page 14 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)42. Have you ever been reduced in rank? Yes NoIf yes, explain and give details (including dates) of all instances:43. How many periods of active military service have you had (Drafts, enlistments or recalls to service)? (providedetails)44. Have you ever been refused enlistment or acceptance by any branch of the Military Service, National Guard, orMilitary Reserves? Yes NoIf yes, explain and give details (including dates) of all instances:Section 6 – Education45. High School Graduation or G.E.D. I possess a High School Diploma. Date received:MM / YYYY I passed the G.E.D. test. Date:Location:MM / YYYY I possess a Certified High School Equivalency or Home School Diploma. I am currently enrolled in a High School / G.E.D. program / Home School program.Anticipated graduation:MM / YYYY46. Have you ever been placed on probation, suspended or expelled from any high school or post‐secondary school(college, university, business, or vocational school) for any academic or disciplinary reason? Yes No If yes, explain and give details (including the school, date, and circumstances) of all instances:Page 15 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)47. Has any high school, college, university, or trade school, etc. advised you of any problems that you have had,such as attendance, difficulty getting along with instructors or fellow students, etc.? Yes NoIf yes, explain and give details (including dates) of all instances:48. List all high schools and/or colleges attended and the dates of attendance:Name: From: To:MM / YYYYMM / YYYYName: From: To:MM / YYYYMM / YYYYName: From: To:MM / YYYYMM / YYYYName: From: To:MM / YYYYMM / YYYYNOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATSection 7 – FINANCIAL HISTORYNOTE: Negative financial history will not be the sole basis for disqualification. The answers in this section shouldpertain to you yourself, not your parents or legal guardians.49. Have you ever been the owner, co-owner, or partner of any business? Yes NoIf yes, explain and give details (dates, company name, address, etc.):50. Have you ever been refused credit in the past seven (7) years? ? YesIf yes, explain and give details: No51. In the past seven (7) years, have your wages been attached or garnished? YesIf yes, explain and give details (including case numbers): NoPage 16 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)52. Have you ever filed or declared bankruptcy? Yes NoIf yes, explain and give details:53. Has the Internal Revenue Service or any other governmental agency ever initiated action to collect past dueincome or other tax payments? Yes No If yes, explain and give details:54. Have you ever failed to file a tax return when required to do so? YesIf yes, explain and give details: No55. Have you ever failed to pay court ordered support payment(s) for any children of whom you are themother/father? Yes No If yes, explain and give details (including case numbers):56. Have you ever failed to pay any court ordered payments of fines (not including parking tickets)? Yes NoIf yes, explain and give details (including case numbers):57. Have you ever taken out any student loans for education or training? YesIf yes, the loan is: Paid No Not PaidIf the loan is not paid, do you have a monthly payback agreement? Yes NoSection 5 – Motor Vehicle Operation58. Do you currently possess a valid driver’s license? Yes NoIf yes, complete the following:State IssuedNumberClass/ClassesExpiration DatePage 17 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)59. List any other state(s) where you have been licensed to drive:State:Name used on license:State:Name used on license:60. Have you ever had a driver’s license under another name? Yes Nodetails:61. Do you currently own any motor vehicles? YesIf yes, complete the following:If yes, explain and give NoStateVehicle Make/ModelYearLicense Plate NumberStateVehicle Make/ModelYearLicense Plate Number62. Within the last five (5) years, has the registration on any of your vehicles been suspended? Yes NoIf yes, explain and give details:63. Do you have liability insurance on each of the vehicles you own? Yes No64. Have you ever been involved in a motor vehicle accident as a driver during the past five (5) years? Yes No If yes, please give details below:Accident DatePoliceInvestigation?Location (including City /State)Police AgencyCitation / Charge Yes No Yes No Yes NoPage 18 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)65. List all traffic citations you have received, including those with charges pending, in the last five (5) years. Donot include parking tickets.DateViolationCity / StateDispositionNOTE** For Out of State Driver’s License please attach an Abstract of your driving record. You can obtain an Abstractwith the Department of Motor Vehicle (DMV) of your home state.NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATSection 6 – CRIMINAL / CIVIL / JUDICIAL HISTORY66. Have you ever been convicted of a crime that was reduced from a felony to a misdemeanor? YesIf yes, explain and give details including dates.67. Have you ever been convicted of a domestic violence related offense? YesIf yes, explain and give details including dates.68. Has a warrant ever been issued for your arrest? YesIf yes, explain and give details including dates. No No NoPage 19 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)69. Have you ever failed to appear in court when properly ordered to do so? YesIf yes, explain and give details including dates. No70. Have you ever had a restraining order and/or an injunction issued against you? YesIf yes, explain and give details including dates. No71. Are you presently under indictment or a defendant in any pending criminal or civil action(s)? YesIf yes, explain and give details. No72. Have you ever been named as a party in a civil action or proceeding as a plaintiff or defendant? (E.g. paternityaction, bankruptcy, eviction, action resulting from non-payment of monies owed, small claims courtproceedings, divorce, child custody hearings, civil lawsuits resulting from auto accidents, industrial accidentsor negligence on your part or on the part of someone else.) Yes No If yes, explain and give details including dates and case numbers.73. Have you ever served time in prison or jail as a result of either a felony or misdemeanor conviction? Yes No If yes, explain and give details including dates.Have you ever been placed on probation/parole as an adult? Yes No If yes, explain and give details including dates.Page 20 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)74. Have you ever been involved in, or present during, a violent incident where someone was or could have beenseriously injured or killed? Yes No If yes, explain and give details including dates.75. Have you ever been a member, or associated with, any gang (E.g. motorcycle gang, street gang, etc.)? Yes No If yes, explain and give details.NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATSection 7 – Drugs / Illegal Substances76. Have you ever failed a mandatory drug screening? YesIf yes, please explain: No77. Have you ever possessed, sold, furnished and/or manufactured any controlled substance, drug, narcotic, or anyother illegal substance? Yes No If yes, please explain and give details.Page 21 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)78. Please provide the following information regarding your use and/or experimentation with any controlledsubstance, without a prescription. Do you now, or have you in the past, used, tried, or experimented with:Drug NameYes / NoEcstasy(Methylenedioxy n methylamphetamine) Yes NoGHB (Gamma‐Hydroxybutyric Acid, etc.) Yes NoCocaine / Crack Yes NoPCP (angel dust, crystal, rocket fuel, KJ) Yes NoAmphetamines / Methamphetamines(uppers, speed, crank) Yes NoBarbiturates (downers, yellow jackets) Yes NoHallucinogens (LSD, STP, DMT, MDA,DET, Synthetic THC) Yes NoPsilocybin (magic mushroom) Yes NoHeroin Yes NoMorphine / Demerol Yes NoMescaline / Peyote Yes NoThai Sticks (Opiated grass) Yes NoAmyl Nitrate (poppers) Yes NoQuaaludes (ludes) Yes NoSteroids Yes NoHashish / Hash Oil Yes NoMarijuana (Grass, Pot) Yes NoNumber ofTimes UsedMonth / YearLast UsedOther – not listed -------- Yes NoPage 22 of 29FC PHQ 19-001
City of Milwaukee Fire and Police Commission Personal History Questionnaire (PHQ)79. Have you ever abused a prescribed drug, narcotic, and/or any other substance?If yes, please explain: Yes No80. Have you ever been involved in glue sniffing and/or used any other such chemical agents for the recreationalor social purpose of obtaining a state of intoxication? Yes NoIf yes, please explain:NOTE: IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL PAGES FOLLOWING THE SAME FORMATSection 8 – GENERAL QUESTIONS81. Have you ever applied for a permit to carry a gun? YesIf yes, provide the following:Permit NumberWhere Granted NoLaw Enforcement AgencyPurpose82. List all occasions in the past where you have been the victim of a reported crime (such as thefts, robberies,burglaries, domestic violence, etc.).83. List all foreign language(s) you read, write, speak and/or understand:84. Have you ever held any city or county license(s) relating to bartending, vending, or transportation? Yes No If
If you need additional space for your response, write your response on a separate sheet of paper and attach it to the PHQ. When you return your PHQ, the documents listed in the Document Checklist (see next pages) must be attached. Your completed PHQ must be received by the FPC b
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The Register, 1615 W. Oklahoma Ave., Milwaukee WI 53215 414-286-5272 (Answering Machine) CURRENT NEWS CONTINUED DOORS OPEN MILWAUKEE (Continued from Page 1) On September 22nd and 23rd, 2018, the fire museum was open for Historic Milwaukee Incorporated's "Open Doors Milwaukee". Over 1,200 people came through the Fire Museum. * * * *
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