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					             Lubbock Fire
             Department
   PROBATIONARY FIREFIGHTER
          APPLICANT

            PERSONAL HISTORY
             STATEMENT FORM

                  2011



Last Name        First Name    Middle Name
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)


                                        Instructions to the Applicant

•   The information you provide in this Personal History Statement (PHS) will be used in the background
    investigation to assist in determining your suitability for the position of Probationary Firefighter, in
    accordance with TCFP, TDSHS, Texas Local Government Code Chapter 143, Local Civil Service Rules
    and City of Lubbock Policy.

•   READ THESE INSTRUCTIONS AND SECTION INSTRUCTIONS CAREFULLY BEFORE
    PROCEEDING. It is essential that all instructions be followed exactly and that complete and accurate
    answers be given for each question, because this will expedite your background investigation. Any
    deadline violation, omissions, falsifications or failures to follow instructions WILL AUTOMATICALLY
    DISQUALIFY YOU as a candidate for this position. Should you have any questions concerning this
    document, call the Lubbock Fire Department at (806) 775-2634.

•   You, the applicant, must print on the PHS legibly, in ink. Do not type. Answer all questions to the best of
    your ability and explain incomplete answers.

•   If a question is not applicable to you, enter N/A in the space provided.

•   YOU ARE RESPONSIBLE for obtaining all correct and complete names, addresses, phone numbers and
    fax numbers (including zip codes and area codes) where requested. If you are not sure of your
    information, verify it personally before submitting your PHS.

•   If there is not sufficient space on a particular page of this form for you to include all requested information,
    copy the Supplemental Narrative Page provided at the back of the PHS. Be sure to indicate on the
    Supplemental Narrative Page that an answer is being continued, reference the relevant section, question
    number, and then place the Supplemental Narrative Page in the proper section.

•   You MUST attach readable PHOTOCOPIES of the following documents:

    a. Birth Certificate                 b. Naturalization Papers (if appl.)         c. Driver’s License
    d. Marriage Certificate/s (if appl.) e. GED Certificate (if appl.)               f. High School Transcript
    g. College Transcript/s (if appl.)   h. Proof of Vehicle Liability Insurance     i. Social Security Card
    j. Entire Dissolution of Marriage Decree/s and all related court orders
    k. Documentation of TCFP Basic Firefighter or higher Certificate
    l. Documentation of TDSHS EMT-B or higher Certificate

*If College or High School transcripts must be obtained by mail, have them sent directly to us at the address
listed below. Send your requests for transcripts through certified mail and attach the certified mail receipt to
your PHS.

•   Failure to return this personal history statement and all required documentation on or before Friday, May
    20th at 5:00 p.m., will result in disqualification. NO EXCEPTIONS. All of this information should be
    returned (either by certified mail, return receipt requested or personal delivery) to the Lubbock Fire
    Department, 1515 E. Ursuline, Lubbock, Texas 79403.




BOTTOM LINE: Be as complete, honest and specific as possible in your responses.




2
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 1: PERSONAL

1. YOUR FULL NAME ~ LAST                          FIRST                             MIDDLE




2. OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOWN BY




3. PHYSICAL ADDRESS WHERE YOU RESIDE ~ NUMBER / STREET / APT



CITY                                             STATE                                ZIP




4. MAILING ADDRESS IF DIFFERENT FROM ABOVE




CITY                                             STATE                                ZIP




5. CONTACT INFORMATION ~ HOME PHONE                  CELL PHONE




WORK PHONE                                           PAGER




EMAIL ADDRESS




6. BIRTH PLACE ~ CITY OF BIRTH               COUNTY OF BIRTH                     STATE OF BIRTH




7. DATE OF BIRTH (MM/DD/YYYY)                                     8. SOCIAL SECURITY NUMBER




9. DRIVERS LICENSE ~ NUMBER                  STATE OF ISSUE              EXPIRATION DATE (MM/DD/YEAR)



10. PHYSICAL DESCRIPTION ~ SCARS, TATOOS, BODY PIERCINGS OR OTHER DISTINGUISHING MARKS



         SEX               HEIGHT FT. IN.      WEIGHT LBS.          HAIR COLOR              EYE COLOR




3
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 2: RESIDENCES
1. RESIDENCES
     •   List ALL residences during the last ten years. Provide complete addresses (include markers such as Street, Drive, Road,
         East, West, etc., and unit or apartment numbers). Do not use P.O. Boxes.
     •   If the residence is a military base, identify name of base in address, nearest city, state, and zip code.


A) ADDRESS WHERE YOU RESIDE NOW ~ NUMBER / STREET / APT                                         FROM              TO

                                                                                                                  Present
CITY                                                         STATE                                          ZIP




B) FORMER ADDRESS ~ NUMBER / STREET / APT                                                       FROM              TO



CITY                                                         STATE                                          ZIP




C) FORMER ADDRESS ~ NUMBER / STREET / APT                                                       FROM              TO



CITY                                                         STATE                                          ZIP




D) FORMER ADDRESS ~ NUMBER / STREET / APT                                                       FROM              TO



                  CITY                                       STATE                                          ZIP




E) FORMER ADDRESS ~ NUMBER / STREET / APT                                                       FROM              TO



                  CITY                                       STATE                                          ZIP




F) FORMER ADDRESS ~ NUMBER / STREET / APT                                                       FROM              TO



                  CITY                                       STATE                                          ZIP




G) FORMER ADDRESS ~ NUMBER / STREET / APT                                                       FROM              TO



                  CITY                                       STATE                                          ZIP




4
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 3: EXPERIENCE AND EMPLOYMENT
1. JOB EXPERIENCE
     •   List ALL jobs you have held since age 17, including part-time, temporary, self-employment, and volunteer. (Begin with your
         most current.)
     •   List ALL periods of unemployment in excess of 30 days.

A) NAME OF EMPLOYER                                                                              FROM               TO


ADDRESS


CITY                                                          STATE                                         ZIP


JOB DUTIES
                                                                                                    F-T      P-T         Temp
                                                                                                    Self-employed         Volunteer
SUPERVISOR’S FULL NAME                                              SUPERVISOR’S PHONE



REASON FOR LEAVING


WOULD THERE BE A                                   IF YES, EXPLAIN:
PROBLEM IF WE CONTACT
YOUR CURRENT EMPLOYER?              Yes     No

B) PERIOD OF UNEMPLOYMENT                                                                        FROM               TO

    Student      Between Jobs       Leave of absence       Travel      N/A     Other ______

C) NAME OF EMPLOYER                                                                              FROM               TO


ADDRESS


CITY                                                          STATE                                         ZIP


JOB DUTIES
                                                                                                    F-T      P-T         Temp
                                                                                                    Self-employed         Volunteer
SUPERVISOR’S FULL NAME                                              SUPERVISOR’S PHONE



REASON FOR LEAVING




D) PERIOD OF UNEMPLOYMENT                                                                        FROM               TO

    Student      Between Jobs       Leave of absence       Travel      N/A     Other ______




5
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 3: EXPERIENCE AND EMPLOYMENT continued
1. JOB EXPERIENCE continued


E) NAME OF EMPLOYER                                                                FROM             TO


ADDRESS


CITY                                                 STATE                                  ZIP


JOB DUTIES
                                                                                    F-T      P-T         Temp
                                                                                    Self-employed         Volunteer
SUPERVISOR’S FULL NAME                                                    SUPERVISOR’S PHONE



REASON FOR LEAVING




F) PERIOD OF UNEMPLOYMENT                                                          FROM             TO

    Student     Between Jobs   Leave of absence   Travel     N/A    Other ______

G) NAME OF EMPLOYER                                                                FROM             TO


ADDRESS


CITY                                                 STATE                                  ZIP


JOB DUTIES
                                                                                    F-T      P-T         Temp
                                                                                    Self-employed         Volunteer
SUPERVISOR’S FULL NAME                                     SUPERVISOR’S PHONE



REASON FOR LEAVING




H) PERIOD OF UNEMPLOYMENT                                                          FROM             TO

    Student     Between Jobs   Leave of absence   Travel     N/A    Other ______




6
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 3: EXPERIENCE AND EMPLOYMENT continued
1. JOB EXPERIENCE continued
     •   If more blocks are needed make additional copies of this page and insert in this section
I) NAME OF EMPLOYER                                                                                 FROM          TO


ADDRESS


CITY                                                           STATE                                        ZIP


JOB DUTIES
                                                                                                      F-T      P-T     Temp
                                                                                                      Self-employed     Volunteer
SUPERVISOR’S FULL NAME                                               SUPERVISOR’S PHONE



REASON FOR LEAVING




J) PERIOD OF UNEMPLOYMENT                                                                           FROM          TO

    Student      Between Jobs        Leave of absence       Travel      N/A      Other ______

K) NAME OF EMPLOYER                                                                                 FROM          TO


ADDRESS


CITY                                                           STATE                                        ZIP


JOB DUTIES
                                                                                                      F-T      P-T     Temp
                                                                                                      Self-employed     Volunteer
SUPERVISOR’S FULL NAME                                               SUPERVISOR’S PHONE


CO-WORKER’S FULL NAME                                                CO-WORKER’S PHONE


REASON FOR LEAVING




L) PERIOD OF UNEMPLOYMENT                                                                           FROM          TO

    Student      Between Jobs        Leave of absence       Travel      N/A      Other ______




7
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 3: EXPERIENCE AND EMPLOYMENT continued

Any “Yes” answer to questions 2 thru 19 must be referenced by section number, question number, and explained on a
Supplemental Narrative Page found at the back of this PHS. The Supplemental Narrative Page should then be inserted
immediately after this page.
2. Have you ever been rejected by the Texas Commission on Fire Protection for certification as a Basic Firefighter?     Yes     No
3. Have you ever been rejected by the Texas Department of State Health Services for certification as an EMT or
Paramedic?                                                                                                              Yes     No
4. Have you ever resigned from a job to keep from being fired?                                                          Yes     No
5. Would any former employer give you an unfavorable recommendation?                                                    Yes     No
6. Have you ever been reprimanded or suspended from work?                                                               Yes     No
7. Have you ever been questioned or investigated by an employer for misconduct?                                         Yes     No
8. Have you ever used sick leave when you were not really sick or caring for a sick family member?
If yes, how much sick leave have you used in the past five years, which was not due to illness? _______________         Yes     No
9. Have you ever been involved in a dispute with a co-worker or fellow employee that required the intervention of a
supervisor or manager?                                                                                                  Yes     No

10. Have you falsified time worked or payroll records?                                                                  Yes     No
11. Have you ever committed an undetected act which, if detected, would have caused you to lose your job?               Yes     No
12. Have you ever slept on the job when you were not authorized to do so?                                               Yes     No
13. Have you ever committed any act of sexual harassment while on the job?                                              Yes     No
14. Have you ever had any type of disciplinary action taken against you for physical or sexual contact while working
on a job?                                                                                                               Yes     No
15. Have you ever had any type of disciplinary action taken against you for any act of harassment of a fellow
employee while on the job?                                                                                              Yes     No

16. Have you ever had any type of disciplinary action taken against you for any act of theft while on the job?          Yes     No
17. Have you ever had any type of disciplinary action taken against you for assisting another person in taking any
items sold by your employer, either by not paying for the items or by paying an incorrect price?                        Yes     No

18. Are you withholding any information relating to your employment history or qualification to do this job?            Yes     No
19. Have you ever falsified an accident, injury or damaged equipment report?                                            Yes     No

20. FIREFIGHTER APPLICATIONS AND EXPERIENCE
     •   If more blocks are needed, reference the section number, question number, and explain on a Supplemental Narrative Page.
Have you ever applied to any fire department?                                                                           Yes     No
     •    If yes, list EVERY department to which you have applied, starting with the most recent (give complete and accurate
          addresses).
     •    All agencies MUST be listed regardless of the outcome or current status. Complete all boxes that apply for each agency.

A) NAME OF DEPARTMENT                                                                                  DATE APPLIED


ADDRESS


CITY                                                             STATE                                           ZIP


CONTACT NUMBER                                                    BACKGROUND INVESTIGATOR’S FULL NAME (IF KNOWN)


STATUS AND REASON IF NOT HIRED




8
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)




SECTION 3: EXPERIENCE AND EMPLOYMENT continued
20. FIREFIGHTER APPLICATIONS AND EXPERIENCE continued
B) NAME OF DEPARTMENT                                                        DATE APPLIED


ADDRESS


CITY                                              STATE                             ZIP


CONTACT NUMBER                                     BACKGROUND INVESTIGATOR’S FULL NAME (IF KNOWN)


STATUS AND REASON IF NOT HIRED




C) NAME OF DEPARTMENT                                                        DATE APPLIED


ADDRESS


CITY                                              STATE                             ZIP


CONTACT NUMBER                                     BACKGROUND INVESTIGATOR’S FULL NAME (IF KNOWN)


STATUS AND REASON IF NOT HIRED




D) NAME OF DEPARTMENT                                                        DATE APPLIED


ADDRESS


CITY                                              STATE                             ZIP


CONTACT NUMBER                                     BACKGROUND INVESTIGATOR’S FULL NAME (IF KNOWN)


STATUS AND REASON IF NOT HIRED




9
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 4: MILITARY EXPERIENCE

1. BRANCH OF MILITARY SERVICE                                                                          FROM                TO


2. TYPE OF DISCHARGE
     Entry Level        Honorable       General         OTH (Other than Honorable)          Bad Conduct          Dishonorable
Re-entry Code (1-4) if applicable – refer to your DD-214: __________
Highest Rank Attained: ____________________________             Rank at Time of Discharge: ____________________________
3. Are you currently participating in one of the following?
     Military Reserve       National Guard    If checked, list unit, supervisor name, location, phone number, and date obligation ends:




4. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s
mast, article 15, letters of reprimand, counseling, etc.)?                                                                      Yes   No

If you answered yes to Question 4, explain (include dates, charges, full name and rank of commanding officer at the time, location you
were stationed at the time, circumstances, and disposition):




10
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 5: REFERENCES
1. REFERENCES
     •  List five (5) persons who know you well enough to provide current information about you.

A) FULL NAME ~ LAST                                           FIRST                                MIDDLE



ADDRESS ~ NUMBER / STREET / APT


CITY                                                         STATE                                  ZIP



                                                                                    LENGTH OF TIME KNOWN
CONTACT NUMBER (S)




B) FULL NAME ~ LAST                                           FIRST                                MIDDLE



ADDRESS ~ NUMBER / STREET / APT


CITY                                                         STATE                                  ZIP



CONTACT NUMBER (S)                                                                  LENGTH OF TIME KNOWN



C) FULL NAME ~ LAST                                           FIRST                                MIDDLE



ADDRESS ~ NUMBER / STREET / APT


CITY                                                         STATE                                  ZIP



CONTACT NUMBER (S)                                                                  LENGTH OF TIME KNOWN



D) FULL NAME ~ LAST                                           FIRST                                MIDDLE



ADDRESS ~ NUMBER / STREET / APT


CITY                                                         STATE                                  ZIP



CONTACT NUMBER (S)                                                                  LENGTH OF TIME KNOWN




11
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 5: REFERENCES continued

E) FULL NAME ~ LAST                                         FIRST                                      MIDDLE



ADDRESS ~ NUMBER / STREET / APT


CITY                                                        STATE                                        ZIP



CONTACT NUMBER (S)                                                                LENGTH OF TIME KNOWN



SECTION 6: MEMBERSHIPS
1. MEMBERSHIPS IN GROUPS, ASSOCIATIONS OR CLUBS
    •   List all present memberships in social, fraternal or professional organizations
    •   If more blocks are needed, reference the section number, question number, and explain on a Supplemental Narrative Page.

A) NAME OF ORGANIZATION                                                                       FROM              TO


TYPE OF ORGANIZATION                                 ADDRESS


CITY                                                        STATE                                        ZIP


CONTACT NUMBER (S)                                                                     EMAIL ADDRESS



B) NAME OF ORGANIZATION                                                                       FROM              TO


TYPE OF ORGANIZATION                                 ADDRESS


CITY                                                        STATE                                        ZIP


CONTACT NUMBER (S)                                                                     EMAIL ADDRESS



C) NAME OF ORGANIZATION                                                                       FROM              TO


TYPE OF ORGANIZATION                                 ADDRESS


CITY                                                        STATE                                        ZIP


CONTACT NUMBER (S)                                                                     EMAIL ADDRESS




12
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 7: EDUCATION
1. HIGH SCHOOL
     •   List the high school from which you graduated – Include a copy of your high school transcript.
Check applicable:
    High School Diploma                             GED                                           Home School Diploma

A) NAME OF HIGH SCHOOL                                                                                 FROM                  TO


                                                    H     th   th           th
GRADES ATTENDED EVEN IF JUST IN PART (9 , 10 , 11 and/or 12 )                                               GRADUATED?
                                                                                                         Yes         No           N/A
ADDRESS ~ NUMBER / STREET / APT


CITY                                                                STATE                                          ZIP


CONTACT NUMBER (S)



2. COLLEGES OR UNIVERSITIES
     •  List all colleges or universities attended – Include copies of transcripts for all colleges/universities attended.

A) Have you ever been expelled, placed on probation or suspended from any educational or training institution?                    Yes   No

B) NAME OF COLLEGE OR UNIVERSITY                                                                       FROM                  TO


TYPE OF DEGREE EARNED                                                                   CREDITS/HOURS COMPLETED


ADDRESS ~ NUMBER / STREET / APT


CITY                                                                STATE                                          ZIP


CONTACT NUMBER (S)



C) NAME OF COLLEGE OR UNIVERSITY                                                                       FROM                  TO


TYPE OF DEGREE EARNED                                                                   CREDITS/HOURS COMPLETED


ADDRESS ~ NUMBER / STREET / APT


CITY                                                                STATE                                          ZIP


CONTACT NUMBER (S)




13
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 7: EDUCATION continued
2. COLLEGES OR UNIVERSITIES continued

D) NAME OF COLLEGE OR UNIVERSITY                                                            FROM           TO


TYPE OF DEGREE EARNED                                                            CREDITS/HOURS COMPLETED


ADDRESS ~ NUMBER / STREET / APT


CITY                                                          STATE                                  ZIP


CONTACT NUMBER (S)



E) NAME OF COLLEGE OR UNIVERSITY                                                            FROM           TO


TYPE OF DEGREE EARNED                                                            CREDITS/HOURS COMPLETED


ADDRESS ~ NUMBER / STREET / APT


CITY                                                          STATE                                  ZIP


CONTACT NUMBER (S)



3. TRADE, VOCATIONAL, BUSINESS OR OTHER SCHOOLS/INSTITUTES
     •  List all trade, vocational or business schools/institutes attended:

A) NAME OF SCHOOL OR INSTITUTE                                                              FROM           TO


COURSE OF STUDY                                                               ADDITIONAL PERTINENT INFORMATION


ADDRESS ~ NUMBER / STREET / APT


CITY                                                          STATE                                  ZIP


CONTACT NUMBER (S)



B) NAME OF SCHOOL OR INSTITUTE                                                              FROM           TO


COURSE OF STUDY                                                               ADDITIONAL PERTINENT INFORMATION


ADDRESS ~ NUMBER / STREET / APT


CITY                                                          STATE                                  ZIP


CONTACT NUMBER (S)



14
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 7: EDUCATION continued
4. BASIC ACADEMIES
     •   List all academies attended for Basic Firefighter and EMT-Basic Certifications.

A) NAME OF ACADEMY                                                                         FROM          TO


NAME OF TRAINING OFFICER/ACADEMY COORDINATOR                                                      GRADUATED?
                                                                                                   Yes        No
ADDRESS ~ NUMBER / STREET / APT


CITY                                                           STATE                              ZIP


CONTACT NUMBER (S)



B) NAME OF ACADEMY                                                                         FROM          TO


NAME OF TRAINING OFFICER/ACADEMY COORDINATOR                                                      GRADUATED?
                                                                                                   Yes        No
ADDRESS ~ NUMBER / STREET / APT


CITY                                                           STATE                              ZIP


CONTACT NUMBER (S)



C) NAME OF ACADEMY                                                                         FROM          TO


NAME OF TRAINING OFFICER/ACADEMY COORDINATOR                                                      GRADUATED?
                                                                                                   Yes        No
ADDRESS ~ NUMBER / STREET / APT


CITY                                                           STATE                              ZIP


CONTACT NUMBER (S)



D) NAME OF ACADEMY                                                                         FROM          TO


NAME OF TRAINING OFFICER/ACADEMY COORDINATOR                                                      GRADUATED?
                                                                                                   Yes        No
ADDRESS ~ NUMBER / STREET / APT


CITY                                                           STATE                              ZIP


CONTACT NUMBER (S)




15
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 8: MOTOR VEHICLE OPERATION
1. List the current driver’s license you possess.

STATE                                                                     D. L. NUMBER



2. List all traffic citations, excluding parking citations, you have ever received:

A) CHARGE (S)                                                                                        AGENCY


DATE CITATION WAS ISSUED                               FINAL DISPOSITION
                                                             Not Guilty       Fined      Defensive Driving    Deferred   Dismissed

B) CHARGE (S)                                                                                        AGENCY


DATE CITATION WAS ISSUED                               FINAL DISPOSITION
                                                             Not Guilty       Fined      Defensive Driving    Deferred   Dismissed

C) CHARGE (S)                                                                                        AGENCY


DATE CITATION WAS ISSUED                               FINAL DISPOSITION
                                                             Not Guilty       Fined      Defensive Driving    Deferred   Dismissed

D) CHARGE (S)                                                                                        AGENCY


DATE CITATION WAS ISSUED                               FINAL DISPOSITION
                                                             Not Guilty       Fined      Defensive Driving    Deferred   Dismissed

E) CHARGE (S)                                                                                        AGENCY


DATE CITATION WAS ISSUED                               FINAL DISPOSITION
                                                             Not Guilty       Fined      Defensive Driving    Deferred   Dismissed

F) CHARGE (S)                                                                                        AGENCY


DATE CITATION WAS ISSUED                               FINAL DISPOSITION
                                                             Not Guilty       Fined      Defensive Driving    Deferred   Dismissed

Any “Yes” answer to questions 3 thru 10 must be referenced by section number, question number, and explained on a
Supplemental Narrative Page found at the back of this PHS. The Supplemental Narrative Page should then be inserted
immediately after this page.
3. Do you have any driver’s license/s other than those you disclosed?                                                    Yes    No
4. Have you ever had a driver’s license suspended for any reason?                                                        Yes    No
5. Have you had more than two (2) events (accidents or moving citations) during the last three (3) years?                Yes    No
6. Have you ever been convicted of failing to appear on a traffic ticket?                                                Yes    No
7. Have you ever been convicted of committing a hit and run accident?                                                    Yes    No
8. During the last five (5) years have you been convicted of driving under the influence of alcohol and/or drugs?        Yes    No
9. Have you ever had a motor vehicle accident in a government vehicle?                                                   Yes    No
10. Have you been denied insurance coverage because of your driving or failed to provide liability insurance on
your motor vehicle?                                                                                                      Yes    No




16
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 9: CRIMINAL HISTORY

Any “Yes” answer to questions 1 thru 31 must be referenced by section number, question number, and explained on a
Supplemental Narrative Page found at the back of this PHS. The Supplemental Narrative Page should then be inserted
immediately after this page.
1. Have you ever been convicted of committing a felony or a misdemeanor other than minor traffic violations?           Yes   No
2. Do you have any charges pending now in a court of law?                                                              Yes   No
3. Have you ever been convicted of any type of sexual assault on another person?                                       Yes   No
4. Have you ever been convicted of engaging in any sexual activity in violation of the law including engaging in any
sexual activity with a person under the legal age of consent?                                                          Yes   No

5. Have you ever been convicted of exposing yourself in a public place?                                                Yes   No
6. Have you ever been convicted of participating in an act of prostitution?                                            Yes   No
7. Have you ever been convicted of engaging in an act of window peeping?                                               Yes   No
8. Have you been convicted of planning to cause the death of another person?                                           Yes   No
9. Have you ever forced anyone to give you their money, property or other valuable against their will?                 Yes   No
10. Have you ever been convicted of taking part in a robbery?                                                          Yes   No
11. Have you ever been convicted of taking part in a burglary of a motor vehicle, habitation, business, building or
coin operated machine?                                                                                                 Yes   No

12. Have you ever been convicted of committing a theft of anything over the value of $10.00?                           Yes   No
13. Have you ever been convicted of committing a theft of a motor vehicle?                                             Yes   No
14. Have you ever been convicted of committing an act of assault on another person?                                    Yes   No
15. Have you ever been convicted of causing or threatening to cause bodily harm to another person?                     Yes   No
16. Have you ever been convicted of starting a fire or causing an explosion with the intent to hurt or damage
another person, property or motor vehicle?                                                                             Yes   No

17. Have you ever been convicted of committing insurance fraud?                                                        Yes   No
18. Have you ever been convicted of forgery?                                                                           Yes   No
19. Have you ever been convicted of using a credit card without the credit card holder’s permission and consent?       Yes   No
20. Have you ever been convicted of intentionally damaging or destroying the property of another?                      Yes   No
21. Have you ever been convicted of making an obscene telephone call?                                                  Yes   No
22. Have ever been convicted of threatening another individual with a weapon?                                          Yes   No
23. Have you ever been convicted of illegally possessing, transporting, manufacturing or selling weapons including
firearms, knives, explosives, incendiary devices or military equipment such as mines, automatic weaponry, armor        Yes   No
piercing ammunition, etc.?
24. Have you ever been convicted of illegally possessing, transporting, manufacturing or selling martial arts
weaponry?                                                                                                              Yes   No

25. Have you ever been convicted of hiring someone or been hired by someone else to set an illegal fire?               Yes   No
26. Have you ever been convicted of damaging any of your own property to collect insurance on it?                      Yes   No
27. Have you ever been convicted of starting a fire?                                                                   Yes   No
28. Have you ever been convicted of planning to destroy property by fire for monetary reasons?                         Yes   No
29. Have you ever been convicted of committing any criminal offense not listed above?                                  Yes   No
30. Have you ever been convicted of illegally or without permission accessing computer records or data?                Yes   No
31. Have you ever been convicted of intentionally changing, altering or destroying computer data without
permission?                                                                                                            Yes   No




17
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 10: ALCOHOL AND DRUG USE

Any “Yes” answer to questions 1 thru 27 must be referenced by section number, question number, and explained on a
Supplemental Narrative Page found at the back of this PHS. The Supplemental Narrative Page should then be inserted
immediately after this page.
1. During the last (2) years, have you consumed alcoholic beverages while driving?                                     Yes   No
2. During the last (2) years, have you been intoxicated in a public place?                                             Yes   No
3. During the last (2) years, have you consumed any alcoholic beverage at work in violation of an employer’s rules,
regulations or policies?                                                                                               Yes   No
4. During the last (2) years, have you consumed any alcoholic beverage when you were on standby and subject to
a call to duty?                                                                                                        Yes   No

5. Have you ever been fired or resigned in lieu of being fired from a job or because of your use of alcoholic
beverages?                                                                                                             Yes   No
6. Are there any reasons why you would not comply with City of Lubbock Policies which stipulate that excessive
use of alcohol, drinking alcoholic beverages while on the job, or violating City substance abuse rules will be         Yes   No
grounds for dismissal?
7. During the last (2) years, have you missed work, school or training as a result of alcohol use?                     Yes   No
8. Have you ever been convicted of illegally possessing, illegally using or illegally selling of alcohol?              Yes   No
9. Have you ever been convicted of using an altered ID or the ID of another person to illegally purchase alcohol?      Yes   No
10. Have you ever been convicted of purchasing or furnishing alcohol for a person you knew to be under the legal
drinking age?                                                                                                          Yes   No

11 Have you been convicted of smoking or ingesting marijuana?                                                          Yes   No
12. Have you ever been convicted of ingesting cocaine or any form of cocaine such as rock, crack, etc.?                Yes   No
13. Have you ever been convicted of using any other illegal substances including, but not limited to, heroin,
hashish, morphine, opium or other opiate derivatives?                                                                  Yes   No
14. Have you ever been convicted of taking any hallucinogenic drug including, but not limited to, LSD, STP,
Psilocybin, Mescaline, Mushroom, etc.?                                                                                 Yes   No
15. Have you ever been convicted of taking/using/ingesting any chemical substances that are stimulants and/or
depressants such as Amphetamines (uppers) or Quaaludes (downers) or other types of stimulant or depressant             Yes   No
drugs?
16. Have you been convicted of using a designer drug such as Eve or Ecstasy?                                           Yes   No
17. Have you ever been convicted of sniffing an inhalant drug for the purpose of getting high?                         Yes   No
19. Have you ever been convicted of taking any prescription medication for any reason other than its prescribed
use?                                                                                                                   Yes   No

19. Have you ever been convicted of using or experimenting with any other illegal drug?                                Yes   No
20. Have you ever been convicted of providing any illegal drugs to another person?                                     Yes   No
21. Have you ever been convicted of manufacturing an illegal drug?                                                     Yes   No
22. Have you ever been convicted of receiving money or other goods from the sale of illegal drugs?                     Yes   No
23. Have you ever been convicted of purchasing any illegal drug?                                                       Yes   No
24. Have you ever been convicted of knowingly transporting and delivering illegal drugs for someone from one
location to another?                                                                                                   Yes   No

25. Have you ever been disciplined or convicted of using an illegal drug while at work or on the job?                  Yes   No
26. If you are selected as a firefighter, are there any reasons why you would not turn in a co-worker for a drug law
violation?                                                                                                             Yes   No

27. During the last twenty-four (24) months have you been with anyone that used an illegal drug in your presence?      Yes   No




18
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SECTION 11: PERSONAL INFORMATION

Any “Yes” answer to questions 1 thru 13 must be referenced by section number, question number, and explained on a
Supplemental Narrative Page found at the back of this PHS. The Supplemental Narrative Page should then be inserted
immediately after this page.
1. Have you ever been convicted of an incident of physical or domestic violence?                                       Yes   No
2. Are you in any way avoiding alimony or child support payments to a former spouse or child?                          Yes   No
3. Have you, within the last five (5) years, been a member of a group or organization that advocates the violent
overthrow of the United States government?                                                                             Yes   No
4. Have you, within the last five (5) years, been a member of a group or organization that advocates violence to any
particular group?                                                                                                      Yes   No

5. Do you have any reasons that prevent you from performing at heights to rescue someone?                              Yes   No
6. As an EMT or Paramedic, do you have any reason/s which would preclude you from administering emergency
medical assistance to a citizen in need?                                                                               Yes   No

7. Do you have any reason/s that would prevent you from fully performing all duties of a Firefighter?                  Yes   No
8. Do you have any objections with the duty hours and job demands of a Firefighter?                                    Yes   No
9. Do you have any reason/s that would preclude you from working overtime, weekends or holidays?                       Yes   No
10. Do you have any objection to working 24-hour shifts, 8-hour shifts or rotating shifts?                             Yes   No
11. Do you have any objection to performing fire inspections?                                                          Yes   No
12. Do you have any objection to performing public education programs?                                                 Yes   No
13. Do have any reason/s that would prevent you from cooperating fully with the examining physician and providing
all pertinent information when you complete the physical survey questionnaire?                                         Yes   No




19
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)


                                    TO RELEASE INFORMATION


I hereby request and authorize you to furnish the City Of Lubbock with any and all information they may
request concerning my employment record, education history, military record, financial status, criminal record,
general reputation, and past or present medical conditions. This authorization is specifically intended to
include any and all information of a confidential or privileged nature as well as photocopies of such documents
if requested. This information will be used for the purpose of determining my eligibility for employment.

I hereby release you and your organization from any liability, which may or could result from furnishing the
information requested above or from any subsequent use of such information in determining my qualifications.


LAST NAME                                       FIRST NAME                          MIDDLE NAME


ADDRESS ~ NUMBER / STREET / APT


CITY                                              STATE                                  ZIP


SOCIAL SECURITY NUMBER                                             DATE OF BIRTH (MM/DD/YYYY)


DRIVER’S LICENSE #                                    SEX                              RACE


OTHER NAMES USED:




APPLICANT SIGNATURE                                                     DATE (MM/DD/YYYY)




NOTE: A copy of this release may be retained in your records.




20
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



I HEREBY CERTIFY THAT THERE ARE NO
WILLFUL MISREPRESENTATIONS, OMISSIONS OR
FALSIFICATIONS IN THE FOREGOING
STATEMENTS AND ANSWERS TO QUESTIONS.
I AM FULLY AWARE THAT ANY SUCH WILLFUL
MISREPRESENTATIONS, OMISSIONS OR
FALSIFICATIONS MAY BE GROUNDS FOR
IMMEDIATE REJECTION OR TERMINATION OF
EMPLOYMENT.



APPLICANT SIGNATURE          DATE (MM/DD/YYYY)




21
PERSONAL HISTORY STATEMENT
PROBATIONARY FIREFIGHTER
(Revised 02/12/2010)



SUPPLEMENTAL NARRATIVE PAGE
If you need more space on any narrative portion of the PHS, write “SEE SUPPLEMENTAL NARRATIVE PAGE” in the margin and use
this page for the narrative portion. Indicate the corresponding section number and question number or letter and insert this
supplement page immediately after the page with the question. Make and insert as many copies of this page as necessary.




22

				
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