2018 FIREFIGHTER

C O N F I D E N T I A L

PERSONAL HISTORY STATEMENT
(BACKGROUND INVESTIGATION BOOKLET)

FOR EMPLOYMENT WITH THE

LITTLE ROCK FIRE DEPARTMENT

Applicant’s Full Name: Click here to enter your name.

CONFIDENTIAL

Supplemental Employment Information

Obtained for Background Investigation Purposes

IMPORTANT INSTRUCTIONS:

(Failure to complete this packet per the following instructions will result in DISQUALIFICATION.)

Answer all questions.

Any falsification or misstatement of any material fact is sufficient to disqualify you from employment.

Your answers to questions contained herein are subject to verification.

If the space provided is inadequate, add additional pages and identify information by name and section number.

Do not misstate or omit material facts. Statements made are subject to verification.

Any question(s) not pertaining to you, please indicate with the letters N/A, meaning not applicable.

Complete all spaces provided.

After completing the fillable form, print and sign on page 12.

Include all of the following required documentation. Ensure all copies are clear & legible:

Original Birth Certificate (CERTIFIED COPY WITH OFFICIAL SEAL)

A clear and legible copy of your birth certificate.

Original High School Diploma and/or G.E.D. Certificate (or official and original transcript which indicates graduation and bearing an official seal)

A clear and legible copy of your High School Diploma, High School Transcript or G.E.D. certificate of the original chosen above.

A clear and legible copy of your driver’s license.

A clear and legible copy of your Social Security card.

Copy of DD-214 Military Discharge (if applicable).

This packet is considered incomplete if the above applicable documents. If any of the above items are NOT submitted with this Background Investigation Booklet/Personal History Statement, your application may be rejected, and you may not be considered further for employment with the City of Little Rock Fire Department. All original documents will be returned to you after review by a Human Resources or Fire Department representative and the copies will be retained and filed with your background application file.

Non-Required Information

College Education, Additional Training and Certification:

You may include copies of college transcripts, specialized certifications or other documentation of additional training. It is your responsibility to provide these copies. Human Resources or Fire Department personnel will not copy these documents for you.

NOTE: Once the packet is submitted, you will not be able to complete, enhance, or correct any of the provided information at a later date. After the packet is submitted, it will be considered to be property of the City of Little Rock Fire Department. If you leave an area blank, please mark N/A or not applicable. It you do not do this, your packet may be considered incomplete.

CITY OF LITTLE ROCK FIRE DEPARTMENT

BACKGROUND INFORMATION FORM

SECTION A – PERSONAL CONTACT INFORMATION

Today's Date: Click or tap to enter a date.

IDENTIFICATION INFORMATION
Last Name: Click here to enter text.	First Name: Click here to enter text.	Middle Name: Click here.	Suffix Click here.
List any other names you have used or been known by, and give reasons for the change. (If none, type N/A.) Click here to enter text.
Present Address (Street, City, State, and Zip Code) Click here to enter text.
Present Mailing or Physical Address (if different from the one above) Click here to enter text.
Home Telephone Number Click here to enter text.	Work Telephone Number Click here to enter text.	Message Telephone Number Click here to enter text.
Date of BirthClick to enter a date.	Present Age Click to enter text.	Place of Birth (Please include a certified copy of your birth certificate.) Click here to enter text.
Race Click here to enter text.	Sex ☐ M ☐ F	Height Click here to enter text.	Color of Hair Click here to enter text.	Color of Eyes Click here to enter text.
Social Security Number Click here to enter text.	*Driver’s License Number and State Click here to enter text.
Do you or did you ever possess a driver’s license issued by a state other than Arkansas? ☐ Yes ☐ No If yes, enter name of state and type of license? Click here to enter text.
*Are you a U.S. citizen? ☐Yes ☐ No	Naturalized Certificate Number Click here to enter text.	If derived, parent certificate number? Click here to enter text.
Please list date, place, and courts for above certificates: Click here to enter text.

*On the first day of employment as a Little Rock Firefighter and continuously thereafter, you must possess a valid Arkansas Driver’s license.

*Please note that applicants are required to be a citizen of the United States to be eligible for hire.

SECTION B - NEPOTISM

If employed in the position for which you have applied, would you be in a supervisory relationship (receive supervision or provide supervision) to any relative or member of your household? Yes ☐ No ☐

If yes, in the space provided below list the full name(s) of the relative(s) and their relationship to you.

Full name of relative Relationship to you Department

1.	Click here to enter text. Click here to enter text. Click here to enter text.

2.	Click here to enter text. Click here to enter text. Click here to enter text.

3.	Click here to enter text. Click here to enter text. Click here to enter text.

SECTION C – U.S. MILITARY SERVICE RECORD

A copy of DD-214 must be included in this packet or you will be disqualified.

DISCHARGE DATE: Click to enter a date.	BRANCH: Click here to enter text.

TYPE OF DISCHARGE: Click here to enter text DISCHARGE RANK: Click here to enter text.

SECTION D – PREVIOUS ADDRESSES

List your HOME ADDRESSES for the previous five (5) years, if different from your current address. Include all addresses while you were in school and the military. If more space is necessary, attach additional pages.

DATES
From To	Street Address	City	State	Zip

Click to enter date.	Click to enter date.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Click to enter date.	Click to enter date.	Click here to enter text.	Click here to enter text.	State	Zip
Click to enter date.	Click to enter date.	Click here to enter text.	Click here to enter text.	State	Zip

SECTION E – EDUCATIONAL/TRAINING RECORD

Education diplomas, certificates, and applicable transcripts shall be furnished by applicant (see requirements on pages 2-3 of this document). Include any fire specific training.

School Name/City/State	Dates Attended	Major Coursework or Subject	Did You Graduate?
High School	Click here to enter text.	Click to enter text.	Click here to enter text.	Click here.
G.E.D.	Click here to enter text.	Click to enter text.	Click here to enter text.	Click here.
College/Univ.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here.
College/Univ.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here.
Graduate School	Click here to enter text.	Click to enter text.	Click here to enter text.	Click here.
Other Training	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here.
Other Training	Click here to enter text.	Click to enter text.	Click here to enter text.	Click here.

What specific or general education or training do you have which has prepared you for a position as a Firefighter with the City of Little Rock? If you have any certificates for completed fire service training, you may include copies with this packet. Please list (exact course title numbers are not necessary):

Click here to enter text.

SECTION F – VIOLATIONS OF LAW

1)	CRIMINAL VIOLATIONS

If you have ever been convicted of or arrested for any CRIMINAL violations of law (felony or misdemeanor) in this State or elsewhere, provide the information requested below for each incident:

Date	Charge	Your Age at Time	Location City And State	Court/Police Disposition (Fine, Sentence, Release)	Name of Police Agency Involved: City, State, Federal
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.

Note: Within any state, the best sources for obtaining this information are the State Police, or the local municipal police department where the violation(s) occurred. Any fees are the responsibility of the applicant. You may attach the received information in lieu of completing this section. However, please write “see attached” in the boxes above. The information required for each column above must be included in the reports or provided above.

Are you required to register as a sexual offender in any state? Yes ☐ No ☐

2)	TRAFFIC VIOLATIONS

List all TRAFFIC Violations within the Last Five (5) Years in this State or elsewhere below for each incident:

Date	Charge	Your Age at Time	Location City And State	Court/Police Disposition (Fine, Sentence, Release)	Name of Police Agency Involved: City, State, Federal
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.
Enter date	Click to enter text.	Age	Click to enter text	Click to enter text.	Click to enter text.

SECTION G – WORK HISTORY

1)	Have you ever been a member of a fire department or similar agency (i.e., public safety)?

Yes ☐ No ☐

If you checked “Yes,” please explain (and list in Employment Record below):

Click here to enter text.

2)	Have you ever been fired or forced to resign from any place of employment? Yes ☐ No ☐

If yes, please explain specific details, the employer, and dates. The employers must be listed under Employment Record below: Click here to enter text.

EMPLOYMENT RECORD: List your jobs for the previous ten (10) years, including full-time, part-time, temporary, military, and self employment, if applicable. Attach additional sheets if there is not sufficient space to cover all of your previous employment for the last ten (10) years. Explain any gaps in employment (see page 12).

BEGIN WITH YOUR PRESENT EMPLOYMENT OR MOST RECENT CURRENT EMPLOYMENT

MAKE EVERY EFFORT TO LIST COMPLETE ADDRESSES AND CURRENT PHONE NUMBERS OF PREVIOUS EMPLOYERS.

Name and Address of Employer (Company): Click here to enter Name.	Title of Position Held: Click here to enter text.	Business Telephone Number: Click here to enter text.
Click here to enter Street Address.	Name of Immediate Supervisor: Click here to enter text.
Click here to enter City, State, Zip.	Ending Salary: Click to enter text.	# of Hrs. Worked Per Wk.: Click to enter text.
Date Employed:	From: Click to enter date.	To: Click to enter date.	# of Employees you supervised: Click here to enter text.
Reason for leaving: Click here to enter text.
Description of work, specific duties: Click here to enter text.
May we contact your current employer prior to a job offer? ☐ Yes ☐ No If no, please explain:

Name and Address of Employer (Company): Click here to enter text.	Title of Position Held: Click here to enter text.	Business Telephone Number: Click here to enter text.
Click here to enter Street Address.	Name of Immediate Supervisor: Click here to enter text.
Click here to enter City, State, Zip.	Ending Salary: Click here to enter text.	# of Hrs. Worked Per Wk.: Click to enter text.
Date Employed:	From: Click to enter date.	To: Click to enter date.	# of Employees Supervised By You: Click here to enter text.
Reason for leaving: Click here to enter text.
Description of work, specific duties: Click here to enter text.
May we contact your current employer prior to a job offer? ☐ Yes ☐ No If no, please explain:

Name and Address of Employer (Company): Click here to enter text.	Title of Position Held: Click here to enter text.	Business Telephone Number: Click here to enter text.
Click here to enter Street Address.	Name of Immediate Supervisor: Click here to enter text.
Click here to enter City, State, Zip.	Ending Salary: Click here to enter text.	# of Hrs. Worked Per Wk.: Click to enter text.
Date Employed:	From: Click to enter date.	To: Click to enter date.	# of Employees Supervised By You: Click here to enter text.
Reason for leaving: Click here to enter text.
Description of work, specific duties: Click here to enter text.
May we contact your current employer prior to a job offer? ☐ Yes ☐ No If no, please explain:

Name and Address of Employer (Company): Click here to enter text.	Title of Position Held: Click here to enter text.	Business Telephone Number: Click here to enter text.
Click here to enter Street Address.	Name of Immediate Supervisor: Click here to enter text.
Click here to enter City, State, Zip.	Ending Salary: Click here to enter text.	# of Hrs. Worked Per Wk.: Click to enter text.
Date Employed:	From: Click to enter date.	To: Click to enter date.	# of Employees Supervised By You: Click here to enter text.
Reason for leaving: Click here to enter text.
Description of work, specific duties: Click here to enter text.
May we contact your current employer prior to a job offer? ☐ Yes ☐ No If no, please explain:

Name and Address of Employer (Company): Click here to enter text.	Title of Position Held: Click here to enter text.	Business Telephone Number: Click here to enter text.
Click here to enter Street Address.	Name of Immediate Supervisor: Click here to enter text.
Click here to enter City, State, Zip.	Ending Salary: Click here to enter text.	# of Hrs. Worked Per Wk.: Click to enter text.
Date Employed:	From: Click to enter date.	To: Click to enter date.	# of Employees Supervised By You: Click here to enter text.
Reason for leaving: Click here to enter text.
Description of work, specific duties: Click here to enter text.
May we contact your current employer prior to a job offer? ☐ Yes ☐ No If no, please explain:

Explain gaps in employment history: Click here to enter text.

SECTION H – PERSONAL REFERENCES

Please provide names of at least three (3) individuals (not relatives or present employers, fellow employees, or former school teachers) whom you have known for longer than one year AND who know you well enough to attest to your character, integrity, and other qualities which will help determine your suitability for employment as a member of the Little Rock Fire Department. Please ensure the addresses are correct, complete, and current so the Fire Department will be able to contact the individuals listed below. It is also essential that the phone numbers are working numbers.

Name: Click here to enter text.	Years Known: Click here to enter text.
Phone #: Click here to enter text.	Business Phone #: Click here to enter text.
Occupation: Click tap here to enter text.	Company Name: Click here to enter text.
Email Address: Click here to enter text.

Name: Click here to enter text.	Years Known: Click here to enter text.
Phone #: Click here to enter text.	Business Phone #: Click here to enter text.
Occupation: Click here to enter text.	Company Name: Click here to enter text.
Email Address: Click here to enter text.

Name: Click here to enter text.	Years Known: Click here to enter text.
Phone #: Click here to enter text.	Business Phone #: Click here to enter text.
Occupation: Click here to enter text.	Company Name: Click here to enter text.
Email Address: Click here to enter text.

SECTION I

I hereby certify that my Personal History Statement (this document) and all attachments to it contain no false information and are complete, truthful and accurate to the best of my knowledge. I understand that should an investigation disclose misrepresentation or falsification of any information on this form or its attachments, my application may be rejected, my name removed from an eligible register, and if I am already employed, I may be dismissed from city employment, and I may be disqualified from applying for future employment with the City of Little Rock.

Signature: Date: Click to enter a date.

(Sign Here)