MARSHALL FIRE DEPARTMENT PERSONAL HISTORY STATEMENT 601 S. Grove Street Marshall, Texas 75670 (903) 935-4580 IMPORTANT DEADLINE INFORMATION Your Personal History Statement will not be accepted after: Day: Friday Date: April 10, 2015 Time: 5:00 o clock PM RETURN TO: Marshall Fire Department 601 S. Grove Street Marshall, Texas 75670 Attn: Chief Joe Hudson DO NOT FAX NOTICE This Personal History Statement must be completed by you in your own handwriting and must be returned by the day, date, and time printed above. If you cannot complete this form and return it to the Marshall Fire Department by the deadline established on this form, you will be disqualified from the selection process and no further action will be taken with your application. Please read all instructions carefully before writing in the Personal History Statement. Any willful omissions, deceptions, or false information will be considered an absolute disqualifier and you will have FAILED this part of your selection process. You will not be processed any further for the position you are applying for, whether the matter is discovered now or at a later phase of the selection process.
SECTION ONE: INSTRUCTIONS READ THESE INSTRUCTIONS CAREFULLY BEFORE PROCEEDING These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is essential that the information be accurate in all respects. It will be used as the basis for a Background Investigation that will determine your eligibility for employment. Answer all questions to the best of your ability. Your Personal History Statement should be printed and legibly completed in your own handwriting using black ink. Do not type your answers. Print your name at the top of each page in the space provided. If a question does not apply to you, enter N/A in the space provided. Do not leave any blanks empty. Avoid errors by reading directions carefully before making any entries on the form. Be sure your information is correct and in proper sequence before you begin. You are responsible for obtaining correct mailing addresses. If you are not sure of an address, check it by personal verification. An internet source or your local library may have a directory service or copies of local phone directories. If there is insufficient space on the form for you to include all information required, complete the supplemental page attached at the end of the Personal History Statement (page 22). Be sure to reference the relevant section and question number before continuing your answer on the supplement page. You may make additional copies of the supplemental page if necessary. All requested documents must be submitted with this Personal History Statement when you return it to the Marshall Fire Department. NOTICE You must successfully complete this Personal History Statement and return it on time in order to proceed to the next phase of your selection process. Listed below are some, but not all, of the areas which will cause you to be disqualified in this process. Failure to turn in the Personal History Statement and requested documents by the deadline established on the cover page. Any willful omissions, deceptions, or false information will be considered an absolute disqualifier and you will have FAILED this part of your selection process. You will not be processed any further for the position you are applying for, whether the matter is discovered now or at a later phase of the selection process. I have read and understand the above notice, all instructions, and agree to complete this Personal History Statement to the best of my ability. I will provide truthful and accurate information. I further understand that if I willfully and intentionally omit information requested in the Personal History Statement, I will be disqualified in the selection process and no further action will be taken with my application. I understand that I must re-apply for this position if I am disqualified. Applicant s Signature Date MFD Personal History Statement 2
Attachments required to be turned in with the Personal History Statement Copy of Driver s License Copy of High School Diploma or GED Certificate Copy of Birth Certificate Copy of TDSHS EMS Certification (if applicable) Copy of TCFP Firefighter Basic or Higher Certification (if applicable) Copy of Military Discharge Papers, DD 214** (if applicable) **In order to receive 5 military service points added to a score of 70 or above, you must submit a copy of your DD-214 showing at least 180 days of active duty and an Honorable discharge.** Copy of College Transcripts (if applicable) Personal History Statements may be hand delivered, mailed, or attached to an email. Faxed Personal History Statements will NOT be accepted. Mailing address: Email address Marshall Fire Department Attn: Chief Joe Hudson 601 S. Grove Street Marshall, Texas 75670 jhudson@marshalltexas.net Phone Number: (903) 935-4573 MFD Personal History Statement 3
SECTION TWO: APPLICANT IDENTIFICATION Information provided in this section is used for identification purposes only. Last Name First Name Middle Name Home Address (complete physical address) Mailing Address if different (complete mailing address) Business Name & Address (complete address) Home Phone Number Mobile Phone Number Business Phone Number ( ) - E-Mail Address ( ) - Website (URL) Including Facebook Height Weight Eye Color Hair Color Social Security Number Driver s License Number, State, and Expiration Date Date of Birth Place of Birth Are you a U.S. Citizen? City County State Scars, Tattoos, Piercings, or Other Distinguishing Marks. List all nickname(s), maiden name, or other names by which you have been known. MFD Personal History Statement 4
SECTION THREE: RESIDENCES List all addresses where you have lived during the past ten (10) years, beginning with your present address. List the date by month and year (example: 10/1997). Complete and attach a supplemental page if needed. FROM TO ADDRESS MFD Personal History Statement 5
SECTION FOUR: WORK HISTORY Beginning with your present or most recent job, list all employment for the past ten (10) years, including part-time, temporary, or seasonal employment. Include all periods of unemployment. Copies of page 8 can be used if supplemental pages are needed. From To Employer (business name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description Reason for Leaving May We Contact for a Reference? From To Employer (Business Name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description Reason for Leaving May We Contact for a Reference? From To Employer (Business Name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description Reason for Leaving May We Contact for a Reference? MFD Personal History Statement 6
SECTION FOUR: WORK HISTORY (Continued) From To Employer (Business Name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description Reason for Leaving May We Contact for a Reference? From To Employer (Business Name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description May We Contact for a Reference? May We Contact for a Reference? From To Employer (Business Name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description Reason for Leaving May We Contact for a Reference? From To Employer (Business Name) Business Address (complete address) Name of Supervisor Your Job Title Business Phone Number Job Description Reason for Leaving May We Contact for a Reference? MFD Personal History Statement 7
SECTION FOUR: WORK HISTORY (Continued) If you served in the Armed Forces, complete the following questions. List your dates of service. Branch of Service (if more than one, list all) To: From: Last Duty Assignment Highest Rank Held Military Service Number Type of Discharge Were you ever disciplined while serving in the Armed Forces (i.e. court-martial, captain s masts, company punishment, etc.)? Charge Type of Hearing Date Age at Time Disposition If you received a discharge other than Honorable, give the type of discharge you received and all details below. MFD Personal History Statement 8
SECTION FIVE: EDUCATIONAL HISTORY High School(s) Attended City & State Dates Attended Graduated College or University Attended City & State Dates Attended Credits Completed Major/Minor Degree Received (if any) Date Received (if any) College or University Attended City & State Dates Attended Credits Completed Major/Minor Degree Received (if any) Date Received (if any) College or University Attended City & State Dates Attended Credits Completed Major/Minor Degree Received (if any) Date Received (if any) Other Schools Attended (Trade, Vocational, Business, etc.) Address Dates Attended Course of Study Certificate Received (if any) MFD Personal History Statement 9
SECTION SIX: SPECIAL QUALIFICATIONS AND SKILLS This area is your opportunity to list all specialized training you may have received. List any special licenses you hold (pilot, radio operator, scuba, etc), show licensing authority, original date of issue, and date of expiration. List any specialized machinery or equipment you can operate. List any foreign languages you have knowledge of and your level of fluency (fair, good, excellent). Language Reading Speaking Writing List any other skills or special qualifications you possess. MFD Personal History Statement 10
SECTION SEVEN: ARRESTS, DETENTIONS, AND LITIGATIONS You must list any and all arrests, detentions, and litigations. Your records will be checked by a Background Investigator and documented in the Background Investigation. Are you currently under indictment for any crime? If yes, state the nature of the indictment, date, and location of case(s)? Have you ever been arrested or detained by law enforcement or summoned into court? (Do not include traffic tickets.) If yes, complete the following: Offense City & State Date Disposition of Case Have you ever been convicted of any offense? Have you ever been on probation for any offense? If you were placed on probation, list the offense(s) and how long you were on probation. If you were placed on Deferred Adjudication or Community Supervision, list the offense(s) and date(s). Have you ever been convicted of any Felony? Have you ever been charged with Driving While Intoxicated or Driving Under the Influence of Drugs? Other than traffic citations, have you ever been fined for any offense? If yes, what was the offense? How much was the fine? Have you ever been a party in Civil Litigation? (Includes divorces and/or custody suits) If you answer yes to any of the above, provide details on the attached supplement page (page 23). MFD Personal History Statement 11
SECTION EIGHT: TRAFFIC RECORD You must list all information relating to your driving record. Your records will be checked by a Background Investigator and documented in the Background Investigation. Has your driver s license ever been suspended or revoked? Do you currently have proper vehicle insurance? If so, what is the name of the Insurance Company? Have you ever held or do you presently hold a driver s license in another state? If so, what state? Date it expired? List, to the best of your memory, all driving citations (tickets) you have received excluding parking tickets. Month & Year Charge City & State Disposition Describe in a brief narrative any traffic accidents in which you were involved. Give the appropriate date and the location of the accident. MFD Personal History Statement 12
SECTION NINE: MARITAL AND FAMILY HISTORY This section addresses your marital and family history. We will contact many of these sources for information to include in your Background Investigation so please be complete and accurate with your answers. What is your current marital status? Single Married Divorced If engaged, list name of fiancée, address, and phone number. Engaged Separated Widowed If married: Date of Marriage City & State Spouse s Name (Wife s maiden name) If separated, divorced, or widowed: Date of Marriage(s) City & State Spouse s Name(s) (Wife s maiden name) Date of Order or Decree(s) Court & State Where Issued List all children related to you or your spouse (natural, step-children, adopted, foster, etc.) Name Relationship Date of Birth Address Supported by Whom MFD Personal History Statement 13
SECTION NINE: MARITAL AND FAMILY HISTORY (Continued) List all other dependants (someone who lives with you or receives 50% of their support from you). Name Address Relationship Age List other relatives in the following order: Father, Mother (include maiden name), Brothers, and Sisters. If deceased, so indicate in the Age column. Name Address Relationship Age MFD Personal History Statement 14
SECTION TEN: FINANCIAL INFORMATION Complete this section with accurate information. This information may be verified by a credit check performed in the Background Investigation. Include company names and correct addresses. Income from spouse should be reported in applicable sections. What is the annual gross income (before taxes) of your current occupation? Do you have income from any source other than your principal occupation? If yes, how much? How often? Source of Income Do you own Real Estate? If yes, what is the value? Location of Real Estate (complete address) Do you have a Savings Account? If yes, what is the average balance? Name of Bank Address of Bank Do you have a Checking Account? If yes, what is the average balance? Name of Bank Address of Bank MFD Personal History Statement 15
SECTION ELEVEN: FINANCIAL OBLIGATIONS List all individuals, companies, and others you are indebted to. Complete all areas to the best of your ability; include rent, mortgages, vehicle payments, charge accounts, credit cards, loans, child support, and any other debt or payments. Name of Creditor Address Loan Type Total Balance Monthly Payment Have you ever defaulted on any type of loan or financial obligation? If yes, use a supplemental page (page 23) to identify the creditor, complete address of creditor, amount owed, and current status of debt. In the past five (5) years, have you filed for bankruptcy or have you had a judgment ordered against you or your property? If yes, use a supplemental page (page 23) to explain. MFD Personal History Statement 16
SECTION TWELVE: REFERENCES List five (5) persons who know you well enough to provide current information about you. Do not list relatives or employers (former or current). Attempt to list local references first, and then out of state references last. All information should be current. Name of Reference Home Address Home Phone Number Mobile Phone Number Business Phone Number ( ) - ( ) - Name of Employer Business Address Years Known Name of Reference Home Address Home Phone Number Mobile Phone Number Business Phone Number ( ) - ( ) - Name of Employer Business Address Years Known Name of Reference Home Address Home Phone Number Mobile Phone Number Business Phone Number ( ) - ( ) - Name of Employer Business Address Years Known Name of Reference Home Address Home Phone Number Mobile Phone Number Business Phone Number ( ) - ( ) - Name of Employer Business Address Years Known Name of Reference Home Address Home Phone Number Mobile Phone Number Business Phone Number ( ) - ( ) - Name of Employer Business Address Years Known MFD Personal History Statement 17
SECTION THIRTEEN: MEMBERSHIP IN ORGANIZATIONS List all organizations that you have been a member of. Include all past and present memberships. This includes professional, social, and fraternal organizations. To From Name of Organization Address Type of Organization MFD Personal History Statement 18
SECTION FOURTEEN: FIREFIGHTERS & APPLICATION FOR OTHER DEPARTMENTS This section is to be used if you are a certified firefighter or if you have been employed and/or applied with other Fire Department Agencies in the past. You should also list any prior application to the Marshall Fire Department. Have you ever applied with this department or any other fire service agency? Agency City State Date Outcome If rejected, do you know why? Have you ever been employed by a fire department? Agency City State Date Position Reason for leaving? List any reprimand(s), suspension(s), or disciplinary action(s) while employed at the any of the above agencies. Agency Date Action Reason? Are you currently licensed with any state agency as a firefighter? If yes, name of agency: Are you currently licensed with any state agency as an EMT-Basic or Paramedic? If yes, name of agency: What agency or academy did you attend to obtain your certification? Agency / Academy Dates Attended State Sponsoring Agency, if any MFD Personal History Statement 19
SECTION FIFTEEN: PERSONAL DECLARATIONS Are there any incidents in your life or details not mentioned within this Personal History Statement, which may be relevant to this Department s evaluation of your suitability for employment as a Firefighter? If yes, please explain in the space provided. I hereby certify that there are no willful misrepresentations, deceptions, omissions, or falsifications in the foregoing statements and answers. I am fully aware that any such attempts will subject me to dismissal from the selection process. Signature of Applicant Date MFD Personal History Statement 20
SECTION SIXTEEN: ADDITIONAL INFORMATION TO SECTION(S) Use this supplemental page for additional information in any section of this Personal History Statement. Please reference the section and question you are answering on this sheet. Use a separate supplemental page for each section. Do not answer questions from two or more sections on the same supplemental page. Insert this sheet after the page it references. You may copy this page to use as needed. Section Number Title Page Number Continue your statement or answer below. Please reference the question you are answering. MFD Personal History Statement 21
BACKGROUND CHECK AUTHORIZATION / DISCLOSURE In processing your application for employment or at any time during your employment period, the City of Marshall may obtain a consumer report and/or an Investigative Consumer Report for employment purposes as authorized by the Fair Credit Reporting Act (FCRA). Federal law requires an employer to make a disclosure statement and to obtain written authorization from the applicant/employee prior to obtaining these reports. If an Investigative Consumer Report is procured, it will be available to you upon written request along with a summary of your rights as defined under the FCRA. THE CITY OF MARSHALL WILL REQUEST A CRIMINAL CONVICTION HISTORY ON ALL APPLICANTS CONSIDERED FOR EMPLOYMENT. A criminal conviction is not necessarily a bar to employment. However, false statements, failure to disclose, or omitting/falsifying information in any part of the application/hiring process will be grounds for immediate elimination from further consideration (or dismissal from employment with the City, if hired). PLEASE PRINT YOUR NAME EXACTLY AS IT APPEARS ON YOUR DRIVER S LICENSE Name: Driver s License Number and State: Social Security Number: Date of Birth: DISCLOSURE STATEMENT By this document, the City of Marshall discloses to you that a Consumer Report, including an Investigative Consumer Report may be obtained from a third party for employment purposes as part of the pre-employment background investigation and at any time during your employment period. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for the City of Marshall to procure a Consumer Report at any time during your employment period. This Consumer Report, including the Investigative Consumer Report may contain but is not limited to: information concerning your prior employment, character, general reputation, education, military service record, criminal history, and personal characteristics / mode of living. Should a Consumer Report and/or Investigative Consumer Report be ordered or requested by a third party, you will have the right to request a complete and accurate disclosure of the nature and scope of the investigations as well as a written summary of your rights under the Fair Credit Reporting Act (see attached). Your signature below acknowledges your understanding of the foregoing disclosure and receipt of the Summary of Your Rights Under the Fair Credit Reporting Act document. Signature of Applicant Date MFD Personal History Statement 22
A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency" (CRA). Most CRAs are credit bureaus that gather and sell information about you - such as if you pay your bills on time or have filed for bankruptcy - to creditors, employers, landlords, and other businesses. You can find the complete test of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade Commission's web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights. You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you - such as denying an application for credit, insurance, or employment - must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report. You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. You can dispute inaccurate information with the CRA. If you tell a CRA that you file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs to which it has provided the data - of any error). The CRA must give you a written report of the investigation and a copy of your report if the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement filed, you may ask that anyone who has recently received your report be notified of the change. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, a CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address, and phone number of the information source. You can dispute inaccurate information with the source of the information. If you tell anyone - such as a creditor who reports to a CRA - that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you've notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA - usually to consider an application with a creditor, insurer, employer, landlord, or other business. Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit of insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. MFD Personal History Statement 23
MARSHALL FIRE DEPARTMENT PHYSICAL AGILITY TEST AGREEMENT STATE OF TEXAS COUNTY OF HARRISON CITY OF MARSHALL By offering this agreement to me, the undersigned, herein after called "Applicant", the City of Marshall, Texas, a home rule municipality, located in Harrison County, Texas, herein after called "City", City agrees to afford applicant an opportunity to take the firefighter physical agility test, which test must be successfully completed by applicant, (according to standards approved by the City), before applicant will be considered for employment by the Fire Department for the City. The date, time and place for administration of said test is as follows: Date: April 18 Time: 1:00 PM Place: ETBU Football Stadium, 1001 Van Zandt, Marshall, Texas 75670 By the executing of this document, applicant acknowledges that he/she has been fully apprised of the nature of the physical agility test, which will be administered by the City. Should applicant be laboring under any disease, physical impairment, or medical/mental condition which could result in applicant being placed or subjected to an increased medical risk while taking such test, and/or should applicant be taking or recently have taken medical treatment and/or medicine which could or will increase the medical risk of applicant, applicant acknowledges that he/she is under duty to reveal same to the City Official administering the agility test prior to the initiation of such test and applicant has or will consult with a physician of his or her choosing prior to the administering of such agility test to determine if such test could be hazardous or harmful to applicant. In consideration for being afforded such test and in consideration for the opportunity for employment by the City, applicant by execution of this agreement below agrees to release and hold harmless the City, its agents, servants, employees, representatives, officers, officials and contractors of and from any claims, actions or causes of action for personal injury or damages of whatsoever kind or nature sustained or suffered by applicant and in any manner occasioned by or arising out of the taking of such test, and applicant further stipulates, acknowledges and agrees that applicant fully and completely assumes all risk and liabilities, in any manner associated with the taking of said test and the mode, manner, time, date and place in which said test is administered and hereby covenants not to bring suit in any court at law or any cause of action in any manner associated with personal injury or damages sustained by applicant while taking said test or in any manner arising out of the taking of said test. This agreement covers the taking of said test at the date, time and place as applicant takes the test, or any part thereof. By offering this test to applicant, City agrees to offer said test to applicant one time only, and further offering of said test to the applicant shall be at the sole discretion of the City, and applicant may drop out of the test at any time, if applicant feels or fears continuation thereof might or could endanger applicant's physical or mental well-being with the understanding that the test must be successfully completed according to the City approved standards before applicant is considered for employment by the Fire Department for the City. By my execution hereof this day of, 20, I hereby certify I have read and understand the above agreement and have been furnished a copy hereof at the time of signing same before in duplicate originals. Applicant's signature Print Name MFD Personal History Statement 24