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? _______


Career Events

9. Please list up to 5 events that stand out the most during your career with the State Highway Patrol.
  1. )_____________________________________________________________________________
  2. )_____________________________________________________________________________
  3. )_____________________________________________________________________________
  4. )_____________________________________________________________________________
  5. )_____________________________________________________________________________

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
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