PERSONAL HISTORY Clause Samples

The Personal History clause requires individuals to disclose relevant information about their background, such as employment history, education, or criminal records, as part of a contractual or application process. Typically, this clause outlines the specific types of personal information that must be provided and may set standards for accuracy and completeness. Its core function is to ensure transparency and allow the other party to assess suitability, trustworthiness, or compliance with eligibility requirements, thereby reducing the risk of misrepresentation or undisclosed issues.

PERSONAL HISTORY. The Employee represents and warrants to the Employer that there is no scandal, whether or not involving a criminal conviction, in his/her past which if made public during his/her employment with the Employer would tend to harm the reputation of the Employer, whether among the public at large or among the clergy, employees or volunteer staff of the Employee.

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PERSONAL HISTORY. Have you had any major injuries or accidents? ❑ No ❑ Yes If yes, please list with dates: Have you had any major illness, surgery or hospitalizations? ❑ No ❑ Yes If yes, please list with dates: Are you pregnant or could you be pregnant? ❑ No ❑ Yes If yes, how many months? Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past. Number of bowel movements daily? Are they? ❑ Loose ❑ Normal ❑ Hard ❑ Incomplete Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past.

PERSONAL HISTORY. Does child walk well? Yes No Run? Yes No Is your child a good climber? Does your child fall easily? Talking? Yes No In phrases? Yes_ _No In sentences? Yes No Does your child speak any other language? If yes, which Physical Disabilities? Yes No Serious Illnesses? Yes No Known Allergies? Yes No Other Conditions or Limitations Is your child toilet trained? Yes No In the process of being trained? Yes No If yes, are you using a potty chair ? Toilet seat ? Does your child have frequent toilet accidents? Yes No How does your child react to accidents? Does your child let you know when he/she needs to use the toilet? Defecate word Vomit word Urinate word

PERSONAL HISTORY. Do you have any conditions, medical or otherwise, that may prevent you from performing your duties as a volunteer for Visiting Neighbors, Inc.? Yes No Do you have any physical limitations or concerns? Yes No Are you presently taking any medications/substances, prescribed or otherwise, that may prevent you from your performance as a volunteer for Visiting Neighbors, Inc.? Yes No Do you have any adverse history regarding financial integrity? Yes No Do you have a drinking or drug problem that would interfere with your ability to perform the service for which you have applied? Yes No Do you have a history of mental or emotional instability for which you have not obtained treatment? Yes No Do you have a history of general behavioral or conduct issues? Yes No Other matters which are important to your performance as a volunteer (list below) Yes No If you answered yes to any of the questions above, please explain:

PERSONAL HISTORY. In order to understand our clients’ background, and to assist in establishing the most suitable structure and banking arrangements (if required), information regarding our clients’ work experience and qualifications is likely to be of considerable assistance, together with a clear understanding of our clients’ source of wealth and financial circumstances both past and present. MINIMUM IDENTIFICATION DOCUMENTS REQUIRED – CORPORATES In the case of clients that are corporate entities we will require the following: 1. Details of the client company’s business, including the nature of the business, source of funds or wealth, annual turnover, asset base, geographical spread of business, number of employees and trading partners. 2. The latest accounts of the company. 3. A certified true copy of the Certificate of Incorporation of the company, and the Memorandum and Articles of Association (or the equivalent). 4. The address of the Registered Office and place of business of the company. 5. If available, a Certificate of Good Standing issued by the Statutory Registry of the country of incorporation of the company or equivalent, proving that the company is in good standing. 6. A Certificate of Incumbency or equivalent, or the results of a company search of the company. 7. A copy of the Board Resolution authorising the client company’s officers to establish a client company and showing who is authorised to issue instructions. 8. Copies of Powers of Attorney or equivalent documents which affect the operation of the proposed client company. 9. Personal identification (as above) for: • All persons authorised to issue instructions AND • Unless otherwise agreed by us, all directors, shareholders and beneficial owners of the client company. CERTIFICATION OF DOCUMENTS Your documents must be certified by a professional person or someone well-respected in your community (‘of good standing’). You could ask the following if they offer this service: • A bank manager of an internationally recognised bank • A lawyer, accountant, notary public, commissioner of oaths or member of the judiciary • A British Embassy Official, serving police officer or doctor It must be noted that the person certifying documents should not be: • related to you • living at the same address • in a relationship with you For certification of ID documents, the certifier should use the following wording: “I confirm that this is a true copy of the original document and that the original document photograph is a...

PERSONAL HISTORY. Do you wear contact lenses? yes no (Please remove contacts prior to Eye Liner procedure.) Have you ever taken or do you now take Accutane? (This is an acne medicine) Yes No IF YES, last dose of Accutane taken: Month Day Year Please list your routine medications here (include herbs and vitamins):

PERSONAL HISTORY. Reason for coming to ▇▇▇▇▇▇▇▇ ▇▇▇▇ (your expectations): Where were you Born/Raised: Marriage History: Children: Grandchildren: Work/Occupation: Education: 🞏 Less than 12 �� High School Graduate 🞏 Some College 🞏 College Graduate 🞏 Post Graduate 🞏 Unknown Life Interests/Accomplishments/Special Life Events:

PERSONAL HISTORY. In answering each of the questions, select the appropriate box next to each question. For each “YES” answer, a separate, signed statement giving full details, including date(s), location(s), action(s), organization(s) or parties involved and specific reason(s) must be included with the application/proctection agreement . Read the definitions listed below before completing the personal history questions. “Ability to practice within your profession with reasonable skill and safety” means ALL of the following: o cognitive capacity, o ability to communicate with patients and other health care providers, o capability to perform health care services within your profession. “Medical condition” means any physiological, mental, or psychological condition, impairment, or disorder, including drug addiction and alcoholism.

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