Personal History Statement (Phs) Page 16
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24Akron Police Division
Personal History Statement (PHS)
53. Have you ever been refused a driver’s license by any state?
Yes
No
If “Yes”, please explain including when, where and why. (Continue on a separate page if necessary)
54. Have you ever applied or obtained a driver’s license or state identification card under a fictitious name?
Yes
No
If “Yes”, explain.
(Continue this response on a separate page if necessary)
55. Ohio law requires that operators and owners of motor vehicles be covered by automobile liability insurance or bond or cash deposit
with the Department of Motor Vehicles. Therefore, please list the current liability insurance you have with your motor vehicles.
Company
Address
Policy Number
Date of Expiration
If you are bonded or have made a cash deposit to meet your motor vehicle financial responsibility, please indicate.
Bond
Cash Deposit $
56. Please list all traffic citations (excluding parking citations) you have received in the last 5 years, starting with the most recent.
If additional room is needed, please continue on a separate page using the same format.
Indicate whether fined or action
Nature of Violation
Location (City State
Approximate Date
taken on driver’s license
57. Have you ever failed to appear in court on a traffic or parking citation?
Yes
No
If “Yes”, was a warrant ever issued?
Yes
No
If “Yes”, please explain on a separate page.
Approx. Date
Violation
City / County / State
Penalty
58. Have you ever been involved in a motor vehicle accident as a driver?
Yes
No
If “Yes”, please give the following information.
Date
Location
Were you at fault?
Injury
Non-injury
Police Investigation?
Police Agency that took report
Were you cited or arrested?
Yes
No
Yes
No
Date
Location
Injury
Non-injury
Police Investigation?
Police Agency that took report
Were you cited or arrested?
Yes
No
Yes
No
Date
Location
Injury
Non-injury
Police Investigation?
Police Agency that took report
Were you cited or arrested?
Yes
No
Yes
No
Page 16 of 24
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