NC Highway Patrol Retirees Association
Personal History
North Carolina State Highway Patrol Hall of History
Questionnaire (Please Print)
Contact Information
1. Name: _______________ ________________ __________ ______
Last First Middle Suffix
2. Current Address: ___________________ ______________ _____ _____
Street City State Zip
3. Telephone: (____)_________________ (____)_____________________
Home Cellular
4. Email Address: __________________________________________________
Employment History
5. When were you employed by the NCSHP? __________/_________
Year Hired / Year Retired/Separated
6. If sworn member, which Basic School did you complete/graduate? #_______
7. If you were a non-sworn member, what position(s) did you hold? (Mechanic, Telecommunicator, Cook, etc.) _________________________ ___________________________________________________________
8. If sworn, what was your RANK when you retired/separated from the State Highway Patrol? _______
9. Please list up to 5 events that stand out the most during your career with the State Highway Patrol.
- )_____________________________________________________________________________
- )_____________________________________________________________________________
- )_____________________________________________________________________________
- )_____________________________________________________________________________
- )_____________________________________________________________________________
10. Would you be willing to give a recorded interview/statement regarding any of your experiences during your employment with the State Highway Patrol? Please circle one. Yes No
Questionnaire continued
Contribution(s) to the NCSHP Hall of History
11. Please check all that apply with regards to your willingness to contribute to the Hall of History.
(A)_______ I am interested in pledging a monetary contribution
(B)_______ I am interested in contributing personal items (eg. books, equipment, etc.)
(C)_______ I am interested in volunteering whenever possible to help support the Hall of History
12. Please tell us anything about yourself, or your experience with the State Highway Patrol that you feel might contribute to the quality and educational value of the Hall of History for future generations to enjoy.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you for completing this questionnaire. We hope that the information you provided will enhance the quality and educational value of the NCSHP Hall of History for past, present and future generations to come. Please return this questionnaire to the person that gave it to you or mail it to:
NCSHP Hall of History
PO Box 1074
Garner, NC 27529
PO Box 1074
Garner, NC 27529