Applicant's SignatureHistory+Statement.docx · Web viewAnabolic Steroids Pharmaceutical drugs not...

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INSTRUCTIONS

This instruction sheet, the Release Form and the Personal History Statement are required to be completed and turned in as requested.

Notarization is required on the Release Form and page 26 of the Personal History Statement.

Items will not be notarized at the Fire D epartment O ffice . This must be completed prior to you turning them in.

Do not fold any of the paperwork!

All responses shall be truthful. OMISSIONS OR INCOMPLETE APPLICATIONS COULD DISQUALIFY YOU.

If unsure of an exact date, use approximate date. (Ex: appx. May 1998)

All juvenile and adult incidents, arrests, convictions and/or illegal drug use must be listed on your application.

Print legibly or type your responses. Use blue or black ink. Do not leave an y blanks.

If additional space is needed for your responses, use only the provided supplemental pages.

Applicant's Signature

R E L E ASE FORM

Name ( Print)

Social Security Number

Date of Birth

To Whom It May Concern:

As an applicant for employment with the City of Chesapeake Fire Department, I hereby authorize the release of such information as may be requested by the City of Chesapeake Fire Department, or its agents. This information may include, but is not be limited to my background, character, education, credit rating, medical and mental health and such other information and supporting documents as may be requested by the City of Chesapeake Fire Department, or its agents.

I hereby authorize the photocopying of any and all such records or information that you may have concerning me.

Signature

Date

City/County of

Commonwealth of

The foregoing instrument was acknowledged before me This day of , 20

Notary Public

-

My commission expires:

Name:Last First M.I

CHESAPEAKE FIRE DEPARTMENT

APPLICANT PERSONAL HISTORY STATEMENT

Page 1POSITION APPLYING FOR: Advanced Life Support Technician

Instructions: FILL OUT THIS QUESTIONNAIRE COMPLETELY AND ACCURATELY. ALL STATEMENTS IN THIS QUESTIONNAIRE ARE SUBJECT TO VERIFICATION. IF THE SPACE PROVIDED IS INADEQUATE, USE THE SUPPLEMENTAL PAGES PROVIDED FOR YOU. TYPE OR PRINT LEGIBLY IN INK ALL RESPONSES. INCORRECT STATEMENTS COULD REMOVE YOU FROM EMPLOYMENT CONSIDERATION.

1. Name: / / Last First Middle Social Security Number

List other names you have used or been known by. Include maiden names, married or adopted names, or nicknames:

2. Present Mailing Address: Number Apt. Street

City State Zip Code

3. Permanent Mailing Address: Number Street

City State Zip Code

Telephone Number: Home: ( ) - Business: ( ) -

Alternate Number: ( ) - E-mail Address:

4. Date of Birth: / / Place of Birth:

City State

5. Are you a U.S. Citizen? Yes: __ No: __U .S. citizenship and proof of such is required for this position.

6. Do you have a valid driver's license? Yes: ___ No: ___If yes, State License Number Expiration

Page 2

7. Have you ever been issued a driver's license from another state other than the one listed above?

Yes: No:

If yes, State License number Expiration

State License number Expiration

8. Have your driving privileges with Virginia or any other state ever been suspended or revoked for any reason? Yes: No:

If yes, which state? Date

Explain reason:

9. Do you have any unpaid parking tickets in this or any other state? Yes: ___ No: ___

If yes, explain. List the city, state, charge and reason why this is outstanding.

10. As a driver, have you ever been involved in a reported or non- reported auto accident?

Yes: No:

If yes, provide the following information:DATE CITY/STATE LIST ANY CITATIONS

ISSUED TO YOUDISPOSITION/

OUTCOME

List all m o ving traffic citations issued to you and the outcome.

Include all citations from the time you started driving until now. Use approximate dates if exact date is unknown.I n clude all citati o ns i s s ued in Vi r gi n ia and/or other states.

Note: If you pre-paid a fine, you were convicted of that offense.** Citations which no longer show on your record must be listed.List citations in order of occurrence starting with the most recent .

DA

TE

CITY/ STATE CHARGE DISPOSITION/OUTCOME FINE PAID?

YES/NO

1 1 . List all non-moving violations issued to you in this or any other state. (Expired inspection, no seat belt, expired tags, etc.)

DATE CITY/ STATE CHARGE DISPOSITION/OUTCOME FINE PAID?YES/NO

Have you ever been arrested, taken into physical custody, been issued a misdemeanor citation.

(Excluding traffic citations), released on your own signature or turned yourself in for any reason?

Yes ___ No ___

Note: Summonses regarding pet or animal offenses must also be listed.

If yes, explain by giving the information below:

DATE AGENCY/LOCATION CHARGE DISPOSITION

Explain in detail all entries above. Use the attached supplemental sheets if necessary.

13. Have you ever been convicted of a felony or misdemeanor?

Yes: No:

If yes, explain by giving the information below:

DATE Agency/Location CHARGE SENTENCE

Explain in detail all entries above. Use the attached supplemental sheets if necessary.

Page 5UNDETECTED CRIMES

14. Have you ever committed, participated in or been present when any of the crimes below were committed or attempted:

Yes No Yes No

Murder Larceny

Arson Shoplifting

Pedophilia Burglary

Rape Manslaughter

Robbery Assault/Battery

Vandalism

Explain any "yes" answers and give dates:

15. Have you ever been questioned by any Law Enforcement authority for any reason other than traffic offenses or motor vehicle accidents?

Yes: ___ No: ___

If yes, give details, date and outcome:

16. Have you ever purchased, sold or been present during the purchase or sale of anything you believed to have been stolen?

Yes: ___ No: ___

If yes, please explain. Give details of the date, the item purchased price, current location of the item and reason you knew/felt the item(s) were stolen.

Page 617. Do you know of, associate with, or reside with any known criminals or convicted felons?

Yes: ___ No: ___

If yes, give details of your relationship with the individual(s) and the criminal conduct/acts they are responsible for:

18. Have you ever used or introduced into your body, b y any means , any illegal drug or substance?

Yes: No:

Complete the drug use chart on the following page. If you have never used any illegal drug, you must indicate so by placing an “X” in the “NO” column by each drug.

Note: Juvenile/Adult "experimentation" MUST be listed!

DRUG YES NO DATE FIRST USED DATE LAST USEDCannabis: (Marijuana, Pot,Weed, Reefer, Mary Jane)

Hashish, Hashish OilCocaine: (Coke, Snow,Candy)Crack: (Freebase Rocks,Rocks)Barbiturates: ( Hypnotics ,or "Downers")Amphetamines: (Ecstasy, Speed, "Uppers")Metha mp hetamine: (Crank, Crystal Met, "Ice")

LSD: or other, (Shrooms,Hallucinogens, Acid)PCP: (Angel Dust, Hog, Peace Pill)Heroin: or other Opiates(Smack, Dope)Inhalants: (Huffing, Sniffing,Bagging)

Anabolic Steroids

Pharmaceutical drugs not prescribed to you

List the name(s) of the pharmaceutical drug(s) not prescribed to you, the reason you used it and how you obtained the drug:

Page 7

19. Is there any other illegal drug, narcotic or substance not listed above that you have introduced into your body?

Yes: No:

If yes, please list it here and include the same information as above:

20. Have you ever sold or purchased any illegal drug?

Yes: No:

If yes, please explain by giving the type of drug, date(s) and circumstances:

21. Have you ever cultivated or manufactured any illegal drug?

Yes: No:

If yes, give detail of incident, date and type of drug (s):

22. Have you ever temporarily stored or "held" any illegal drug, narcotic or substance?

(EXCLUDE ENTRIES FROM QUESTION #18)

Yes: No:

If yes, please explain giving date(s), type of drug and circumstances:

23. Have you ever been present when drugs were bought, sold or used?

Yes: No:

If yes, please give date(s), type of drug and detail of each incident:

Page 8

EDUCATION

24. The Virginia State Code requires Firefighters to possess a high school diploma or its equivalent. Please indicate your current status with regard to this requirement. A college degree is not required for this position.

I possess a high school diploma

I possess a GED certificate

I possess a college degree(s)

Please include the type of degree, name of college and the year degree was attained:

25. List the educational institutions you have attended starting with your high school to the present. Include any colleges, vocational, military, or business schools.

Name of School

City / State Dates of Attendance

Certificates/Degree Earned

EMPLOYMENT HISTORY

26. List all jobs you have held within the last 10 years.

Begin with your most current employment. Include militar y service, part time, temporary or volunteer employment.

DO NOT LEAVE ANY BLANKS!

Correct phone numbers and addresses must be listed.

Name of employer:

Address, city, state, zip:

Area code and Phone number: ( ) -

Your job title/duties:

Name you were known by:

Full-time: Part-time:

Voluntary Dates of Employment: From: To:

Name of Supervisor: Title:

Beginning Salary: Ending Salary:

Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):

Have you ever been written up, counseled or disciplined for ANY Reason?

If so, list reason and outcome:

Page 10

Name of employer:





Full-time: Part-time: Voluntary:

Dates of Employment: From: To:



Details o f reason for leavi n g ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):

Have you ever been written up, counseled or disciplined for ANY reason?If so, list reason and outcome:

Name of employer:







Name of Supervisor:

Beginning Salary: Ending Salary::

Page 11Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):

Have you ever been written up, counseled or disciplined for ANY reason?


Name of employer:

Address, city, state, Zip:






Name of Supervisor:



Page 12



Name of employer:












Name of employer:







Name of Supervisor Title:


Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an

acceptable reason):



Name of employer:









Details o f reas o n for leav i n g ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):



Name of employer:


Area code and Phone number: : ( ) -










27. Have you experienced periods of unemployment?

Yes: No:

If yes, give the dates:

From: To:

From: To:

From: To:

Reasons for unemployment:

28. Have you ever been terminated, discharged, or asked to resign from any position for derogatory reasons?

Yes: No:

(Include terminations outside the previous 10 years listed)

If yes, complete the following:

Name of employer/company:

Address City State

Supervisor's name/Title

Phone Number

Dates of employment From: To:

Position held:

Details of termination:


Address City State

Supervisor's name/Title Phone Number


Position Held:

Details of Termination:


Address City State

Supervisor's name/Title Phone Number


Position Held:

Details of Termination:

29. Have you ever been forced to resign or been terminated from any position due to conflicts with supervisors, co-workers, schedules, or position held?

Yes: No:

If yes, explain

30. Have you ever accepted, taken or given away merchandise, supplies or food from an employer?

Yes: No:

If yes, please complete the following:

Name of Employer: Your position/T Items taken:

What was the value of the item(s):

How many times did this occur?

Dates of Occurrence(s):

Was this done without permission?:

Name of Employer: Your position/T

Items taken:

What was the value of the item(s):



Was this done without permission?

31 Have you ever taken any money from an employer? Yes: No:

If yes: please complete the following:

Name of Employer

Your position/Title:

Amount?:




Explain:

Name of Employer:

Your position/Title:

Amount?




Explain:

(

(

Page 19

32. What previous employment did you like the most and why?

33. The least liked and why?

34. Have you ever accepted employment with any Fire or Emergency Medical Service Agency?

Yes: No:

If yes, complete the following:

Agency’s Name:

Address of Agency:

Are you still employed with this agency? Yes: No:

Position/Title:

If still employed reason for seeking other employment?

If not, details of your resignation/termination?

35. Have you ever made application for employment (any position) with this or any other Fire or Emergency Medical Service Agency?

Yes: No:

If you have placed more than one application in with an agency, you must complete the information below for each time. Use supplemental pages if needed.

Agency's Name:

Year applied:

State:

Position applied for:

Check all the application phase( s) you completed:

Written Agility B-pad Interview

Background Polygraph Psychological

After which phase were you not selected or disqualified from?

Explain the reason you were given:

Agency's Name: State:

Year applied:


Check all the application phase( s) you completed:






Year applied:


Check all application phase(s) you completed :






Year applied:


Check all application phase(s) you completed :





Page 22

MILITARY SERVICE

32. Are you registered with the Selective Services? ( registration for military draft)

Yes: No:

If yes, when?

33. Have you ever enlisted in any branch of service for any period of time?

Yes: No:

If yes, fill out the following:

Branch of service Rank at discharge

Dates of service Type of Discharge

34. While in the service were you ever verbally reprimanded, written up, disciplined, been the subject of judicial or non-judicial punishment, charged with Article 15, Captain 's Mast or Court martialed?

(All must be listed, even if it is no longer in your record.)

Yes: No

List the charge(s)

If yes, please give details of each (if multiple occasions) to include the date, detail of

circumstances and outcome (extra duty, drop in rank, pay, counseled, etc.):

Page 23

Personal

35 Do you own an automobile?

Yes: No:

If yes, give make, model, and year:

36. Do you have automobile insurance, assigned risk or certification of compliance with the Uninsured Motor Vehicle Act?

Yes:_______No:_______

38. Marital Status:

Single:_____Married: Divorced:_______Separated:______

39. Name of Spouse :

40. List your parents, brothers and sisters.

Father MotherBro. /Sis. Bro. /Sis.Bro./Sis Bro ./Sis.

41. Give the names of three (3) responsible persons, other than relatives or past employers, could provide information about your character, abilities, experience, personality and other qualities.

1.Name Address Phone number

2. Name Address Phone number

3 . Name Address Phone number

42. Begin with your present address and list all previous places you have resided during the last ten (10) years. List the apartment if applicable.

Address City/State From: To:










43. As an adult, list all cities and states you have resided in; permanent and/or temporary.

City State City State



Financial (Financial irresponsibility in itself is not an automatic disqualifying factor)

44. Have you ever filed for or declared bankruptcy? Yes: No:

If yes, please give details to include when, where, why and chapter filed.

45. Within the last 7 years, have any of your debts been turned over to a collection agency?

Yes: ________ No:

If Yes, please give details to include when, what account(s), why and whether the debt(s) is clear or balance still due.

46. Within the last 7 years, have your wages ever been garnished? Yes: No:

If yes, please give details to include when, where and why.

47. Within the last 7 years, have you ever had any goods repossessed?

Yes: No:

If yes, please explain when, and what circumstances.

48. Have you ever been delinquent on child support, alimony, income tax or other tax payments?

Yes:___ No:

If yes, please give details to include when, where, why and whether the account(s) is paid in full and/or currently in good standing.

I hereby certify that all statements made in this questionnaire are true and complete and authorize the verification of this fact by the Personnel Officer of the Fire Department. I understand that any misrepresentation of material facts, in addition to the omission of information, could subject me to disqualification or termination.

Applicant's Signature

Date

THIS PAGE MUST BE NOTARIZED

City/County of

Commonwealth of_______________________The foregoing instrument was subscribedSworn before me this day of (month) , (Year)

b y_____________________________________________________

Notary Public’s Signature

My commission expires

Use these supplemental pages to include additional information or to further explain any responses from your Personal History Statement.

List the question number you are referencing

INITIAL EACH SUPPLEMENTAL PAGE USED

Initials:_____

Supplemental Page 1

Initials:_____

Supplemental Page 2

Supplemental Page 3

Initials:_______

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