Dallas Fire-Rescue Personal History Statement

Transcription

1 Recruiter: Date: Dallas Fire-Rescue Personal History Statement Place a current passport photo in the box. This Personal History Statement will need to be returned to the recruiting office no later than 5:00 p.m. on MARCH 31, 2015; or if mailed, postmarked by this date. Mailing address: Dallas Fire-Rescue / Recruiting 5000 Dolphin Road Bldg. A Dallas, TX ATTENTION: All applicants, if we receive your Personal History Statement INCOMPLETE or it is not legible, your application may be eliminated from the hiring process. If your application is not in the recruiting office on the date indicated, this will eliminate your application from the hiring process. The following documents are required and must be attached with PHS (if applicable). 1. Copy of Birth Certificate 2. Copy of Driver s License (current/updated) 3. Copy of High School Diploma 4. 4 (only 1 required with Personal History Statement) official College transcripts** 5. Military Form DD Proof or documentation of Community Service **XEROX COPIES of transcripts will not be accepted.**

2 DALLAS FIRE-RESCUE PERSONAL HISRY STATEMENT Application for Fire-Rescue Officer: Date: **All information supplied in connection with your application will be held in strict confidence. information will be released without your waiver of release.** No GENERAL INSTRUCTIONS: TYPE OR PRINT an answer to every question. If question does not apply to you, answer with N/A. If space available is insufficient, use a separate sheet to answer and indicate the corresponding number. IF HAND PRINTED, USE BLACK INK ONLY. DO T MISSTATE OR OMIT material fact since the statements made herein are subject to verification to determine your qualifications for employment. 1. LAST NAME FIRST NAME MIDDLE NAME 2. MALE FEMALE 3. ALIAS/NICK NAME/MAIDEN NAME 4. PHONE HM: WK: CELL: 5. SOCIAL SECURITY. ADDRESS 6. PRESENT ADDRESS STREET APT# CITY, STATE ZIPCODE 7. DATE OF BIRTH (MO., DAY, YR) PLACE OF BIRTH 8. HEIGHT WEIGHT EYE COLOR HAIR COLOR 2

3 9. U.S. CITZEN SEEKING CITZENSHIP? NATURALIZATION CERTIFICATE. 10. MARITAL STATUS: MARRIED SINGLE DIVORCED WIDOWED SEPERATED (EMERGENCY CONTACT INFORMATION) NAME TELEPHONE RELATIONSHIP 11. LIST ALL PREVIOUS ADDRESSES SINCE THE AGE OF 18 CITY STATE YEAR YEAR (A) (B) (C) (D (E) (F) 12. MILITARY STATUS Have you served in the U.S. Armed Forces? While in the military service, were you ever disciplined, arrested or court-martialed? If yes, give date, place, law enforcing authority or type of discipline, or court-martial, charge and action taken for each incident. DATE PLACE AGENCY CHARGE DISPOSITION 3

4 Last duty Station and Name of Commanding Officer: Are you presently a member of U.S. Reserve or National Guard organization? GRADE AND SERVICE. BRANCH OF SERVICE ORGANIZATION AND STATION OR UNIT AND LOCATION: ACTIVE INACTIVE STANDBY INDICATE RESERVE OBLIGATION, IF ANY. LIST TYPE OF DISCHARGE IF APPLICABLE: 13. EDUCATION A. List High School attended: NAME CITY ZIP CODE B. Higher Education. List information below for all colleges or universities attended. NAME AND LOCATION OF DATES ATTENDED CREDIT HOURS DEGREE COLLEGE OR UNIVERSITY / REC D REC D 4

5 MAJOR MIR If you are currently enrolled in college, how many semester hours? Please list any other certifications applicable to the position you are seeking: C. Have you ever been expelled or suspended from a college or university? If yes, explain: 13. VEHICLE OPERAR S LICENSE: Give the following information concerning any vehicle operator s license CLASS STATE D.L. NUMBER EXP. DATE RESTRICTIONS Have you ever been denied issuance of a license or have you ever had a license suspended or revoked? If yes, explain 5

6 14. EMPLOYMENT: Begin with your most recent job and list all previous employment, including periods of unemployment, (list periods as a student also) BUSINESS NAME COMPLETE ADDRESS PHONE # / FAX # START DATE / END DATE JOB TITLE/DESCRIPTION OF DUTIES REASON FOR LEAVING BUSINESS NAME COMPLETE ADDRESS PHONE # / FAX # START DATE / END DATE JOB TITLE/DESCRIPTION OF DUTIES REASON FOR LEAVING BUSINESS NAME COMPLETE ADDRESS PHONE # / FAX # START DATE / END DATE JOB TITLE/DESCRIPTION OF DUTIES REASON FOR LEAVING BUSINESS NAME COMPLETE ADDRESS PHONE # / FAX # 6

7 CONTINUED START DATE / END DATE JOB TITLE/DESCRIPTION OF DUTIES REASON FOR LEAVING BUSINESS NAME COMPLETE ADDRESS PHONE # / FAX # START DATE / END DATE JOB TITLE/DESCRIPTION OF DUTIES REASON FOR LEAVING 15. ARREST, DETENTION, AND LITIGATION A. Have you ever been arrested or detained by a law enforcement agency? B. Have you ever been fingerprinted for any reason (arrest, job applicant, etc.)? C. Are you currently involved in any pending civil or criminal litigation? D. Have you ever been named in a protective order, restraining order or other similar type of document? E. Have you ever been convicted of a DUI (driving under influence), DWI (driving while intoxicated), MIP (minor in possession), or PI (public intoxication)? F. Have you ever been placed on probation or received deferred adjudication? If the answers to any of the previous questions are, list below the date, place, and full details of each incident. 7

8 List all traffic violations and or motor vehicle collisions in this state or elsewhere. DATE CHARGE NAME OF LAW ENFORCEMENT AGCY. CITY & STATE 16. RECREATIONAL ACTIVITY: Do you drink alcohol? Approximately, how many drinks per week? Have you ever had counseling for alcohol use? Have you ever smoked or experimented with marijuana? If, yes, approximately how many times? Date last used Have you ever used any controlled substance? If yes, please list types and number of times used FOREIGN LANGUAGES, Please list any Foreign Languages you speak fluently 18. Are there any incidents in your life not mentioned here which may reflect upon your suitability to perform the duties for the applied position or which might require further explanation? Please explain: 19. REFERENCES: Please list 5 personal references (non-related) Name Phone# Year s known Address Occupation 8

9 Name Phone# Year s known Name Phone# Year s known Name Phone# Year s known Name Phone# Year s known Address Occupation Address Occupation Address Occupation Address Occupation 20. What characteristics do you have that would contribute to your being a Dallas Fire-Rescue Officer? 21. Please list and or provide proof of Community service and list any type of documentation for volunteer work you have done. 9

10 Waiver of Liability I represent and warrant that the answers I have provided to each and all of the foregoing questions are full and true to the best of my knowledge and belief. In order that the officials of the City of Dallas may be fully informed as to my personal character and qualifications for employment, I refer to each of my former employers and to any other person who may have information concerning me. As this information is furnished at my request and for my benefit, I do hereby release them from any and all liability for damage of whatsoever nature an account of furnishing such information might incur. I acknowledge that any false statements knowingly made in answering the above questions is good cause for removal from the eligibility register or discharge during or after probation. Signature of Applicant Date 10