attention! - waco, texas application 2013.pdf · civil service testing • registration and...

CITY OF WACO

ATTENTION!

Fire Department John D. Johnston

Fire Chief 1016 Columbus Ave. Waco, Texas 76701 254/750-1740 Fax 254/750-1769

Due to the length of this application packet, you are encouraged to return the completed application in person to Waco Fire Administration at 1016 Columbus Avenue, Waco, Texas, to insure the packet is complete.

Office hours are 8:00a.m. to 5:00p.m. (Monday-Friday). Please be sure that all copies of required documentation are legible.

Incomplete applications received by mail (whether they are lacking documentation, have blank lines, include copies not readable, etc.) will not be processed.

Upon receipt of a completed application, a study guide will be available.

PLEASE NOTE

DEADLINE FOR APPLICATIONS IS 5:00P.M., CST, ON FRIDAY, MAY 31., 2013,

NO EXCEPTIONS.

Thank you for your interest in the Waco Fire Department.

Updated 05/03/2013 01 0.13- Packet Cover Sheet

GENERAL INFORMATION REGARDING EMPLOYMENT as an

ENTRY LEVEL FIRE FIGHTER for the

CITY OF WACO, TEXAS

APPLICANT QUALIFICATON REQUIREMENTS: • Be a minimum of 18 years of age and not have reached their 36th birthday

prior to hiring • Possess a high school diploma or G.E.D. with 12 college hours • Visual acuity of at least 20/1 00 in each eye, correctable to 20/20 and free of

color blindness • Possess a valid Texas drivers license at the time of appointment • Meet all other requirements of the Civil Service Commission of the City

ofWaco, Texas

EMPLOYMENT PROCESS • Application Packet • Civil Service Examination • Civil Service Agility Course • Extensive Background and Credit Investigation • Polygraph Test • Oral Interview • Final Interview • Letter of Acceptance/Denial • Conditional Offer of Employment • Physical Examination

APPLICATION PACKET • Entire application MUST be completed in the applicant's own

handwriting. • Must be completed as directed • Attachments must include copies of the following:

1. High school diploma and high school transcripts or G.E.D. 2. Valid Texas drivers license (must have current address) 3. Social Security card 4. DD 214 for military credit (if applicable) 5. Copy of Certificate or a copy of official examination grade from Texas

Commission on Fire Protection and valid EMT-B certificate from Department of State Health Services (if applicable)

6. Copy of all college transcripts. 7. Any other documentation that you feel would be helpful. (Examples:

SCUBA,HAZMAT, ARFF, etc.) 8. Signed and notarized copies of all waivers in packet

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HOURS- Normal duty hours are 24 on and 48 off

DISQUALIFICATIONS • Does not meet age requirements • Is not a citizen of the United States • Cannot effectively read and write the English language • Physically or mentally unfit for the performance of duties as a fire fighter • Undesirable character or reputation • Convicted of a felony or any crime involving moral turpitude • Habitual user of alcoholic beverages to excess • Addicted to or habitual user of narcotics/controlled substances • Dismissed from public service for delinquency or misconduct • Made false statements of any material fact or practiced or attempted to

practice any deception or fraud in the application, examination, or appointment

• Found to lack any of the minimum qualifications set forth in the published notice for applicants

• Does not meet requirements of the Nepotism Policy for the City of Waco • Failure of the polygraph test • Incomplete application

RETURN OF APPLICATION PACKET • Completed application packets must be returned to Waco Fire Administration,

1016 Columbus Avenue, Waco, Texas 76701 • Study guides will be available upon return of packet • All application packets must be returned no later than 5:00 PM CST on

Friday, May 31,2013. Any application received after this date and time will be refused.

CIVIL SERVICE TESTING • Registration and processing will begin at 6:30a.m. on Saturday, June 8, 2013

at the Waco Convention Center located at 100 Washington Ave., Waco, Tx, 76702.

• Written examination will begin at 8:00a.m. at the same location. • A predetermined number of applicants will be permitted to take the Physical

Agility Course on Saturday, June 8, 2013, at 1:00 p.m. The course is located at the Emergency Services Education Center, 7601 Steinbeck Bend Rd, Waco, Tx. (Maps will be provided)

• If weather prevents the Agility Course testing, it will be rescheduled for a later date to be determined by the Waco Fire Department.

• Applicants must wear appropriate clothing in consideration of weather conditions for the Agility Course. Appropriate clothing is considered to be comfortable attire such as tennis shoes, shorts, and T -shirts (No tank tops or


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sleeveless shirts) for normal conditions and sweat shirt and pants for colder conditions.

READ THESE INSTRUCTIONS CAREFULLY BEFORE PROCEEDING

These instructions are provided to assist you in properly completing your Personal History Statement. It is of utmost importance that the information you provide be accurate in all respects. This information will be used as the basis for your background investigation that will ultimately determine your eligibility for employment as a fire fighter for the City of Waco, Texas. Make sure that you understand each document prior to placing your signature on these documents.

1. Print legibly. Your Personal History Statement must be legible. Answer all questions completely. Incomplete applications will be rejected.

2. Should a question not be applicable to you, enter NA in the space provided. Do not leave any blank spaces unanswered.

3. You are responsible for obtaining correct addresses to include street address, state, zip codes, and phone numbers if requested. If you are not sure of an address, check it by personal verification. Your local library may have directory service or copies of local telephone directories.

4. Avoid errors -by reading and understanding directions carefully before making any entries.

5. If there is insufficient space on the forms to include all information required, attach extra sheets of paper to the Personal History Statement. Be sure to reference the relevant section and question number before continuing your answer. Use only 8.5 X 11-inch paper for these attachments.

6. Accurate information and complete forms will expedite our background investigation of you. Failure to respond to any question, deliberate omissions, or falsifications will result in disqualification.

7. After the application has been submitted, you are responsible for notifying our Administration Office within 10 days of any changes in the information provided. The contact number is 254-750-1740. Office hours are 8 AM- 5 PM Monday through Friday.

FireAdm/CSApplication/ ApplicationFolder/Genera!Information dm


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WACO FIRE DEPARTMENT EMPLOYEE APPLICANT DRUG AND ALCOHOL POLICY

Statement of Policy

The Waco Fire Department is a safety and information sensitive work environment. Due to these concerns and the commitment of providing excellence in public service, it is imperative that the best-qualified persons be selected as employees of the Waco Fire Department. There exists a societal problem with the use of illegal substances and the Department recognizes there are circumstances that exist where an individual may have experimented with some substances. The following are the established guidelines for determining the eligibility of both Fire and Civilian applicants.

AUTOMATIC DISQUALIFIERS

• DWI, DUI, or MIP or any alcohol related offense within the last 3 years. Conviction more than once for any of these offenses is an automatic disqualification.

• Manufacture, production or sale, with or without profit, of any drug listed in The Texas Controlled Substance Act.

• Any Injection of a controlled substance or dangerous drug, without a prescription or under medical supervision.

• Any use of the following specific illegal drug(s) and/or substance(s):

A. Steroids after September 1989 B. Any Schedule I Drug (Heroin, Ecstasy, Psilocybin, PCP, LSD, Mushrooms) C. Cocaine (Powder, Crack or in combination with any other substance) D. Any Hallucinogens

• Inhalant use within the previous five years. Illegal inhalants include any substance containing a "volatile chemical" as defined in chapter 485.001 of the Texas Health Safety Code.

• Marijuana usage, beyond experimentation, includes but is not limited to smoking or inhalation, use of hashish, or ingestion of the substance (i.e., "Brownies" etc ... ).

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*MAY BE AN AUTOMATIC DISQUALIFIER

1. Illegal drug use after the age of 24. 2. Any drug use while employed for another Emergency Services Agency. 3. Conviction more than once for any drug listed in The Texas Controlled Substance

Act. 4. Furnish/provide alcohol to a minor or allow a minor to consume in or on your

property within the last 3 years.

CONTROLLEDSUBSTANCESillANGEROUSDRUGS

Applicants must not have used any other illegal drug or controlled substance within five (5) years.

Civilian Applicants

All civilian applicants, from time of application, are expected to meet the same established guidelines as stated above for determining eligibility of employment with the Waco Fire Department.

This policy was accepted and approved as the current Drug Policy for the Waco Fire Department on August 15, 2004; amended March 1, 2010.

Jolin 'D. Johnston Fire Chief

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City of Waco Application for Employment 300 Austin Avenue + P.O. Box 2570 + Waco, Texas 76702-2570 + www.waco-texas.com

INSTRUCTIONS: Answer each question clearly and completely. If questions are not applicable, enter "NA". Do not leave questions blank. Be sure to sign when completed. Incomplete applications will not be considered. If more space is required for any question, please attach additional sheets as necessary. Resumes will not be accepted in lieu of an application; you may attach a resume to this completed application. This application will only be considered for the position applied for. To be considered for other positions you will need to complete an additional application per position. The City of Waco is an Equal Opportunity Employer and all applicants will receive consideration without regard to race, color, religion, national origin, gender, age, and veteran or disability status.

General Information

Name ------------------------

Today's Date ------------

Social Security Number ---------Last, First, Middle Initial

Address ------------------------------------------Number, Street, City, State, Zip Code

Home Phone----------- Work Phone ---------- Other Phone -------

Email Address ---------------------

Position Title Applying For ---------- Requisition Number ------ Supervisor ------

Date You Are Available to Work Are you 18 or older? DYes DNo If no, how old? __ _

If hired, can you provide legal proof that you are legally entitled to work in the United States? DYes DNo

Do you speak, read, or write languages other than English? DYes DNo

If yes, what languages? ----------- How well? DGood DFair DExcellent

Are you related by blood or marriage to any City of Waco employee or Council Member? DYes DNo

If yes, please list: Name Department/Division

Are you currently or have you ever been employed by the City of Waco? DYes DNo If yes, please list position(s), department(s), dates and reason(s) for leaving.

Position Department Dates (From/To)

Criminal History

Relationship

Reason for Leaving

The City of Waco conducts criminal history checks on all employees. Please fully answer the following questions. (Please note: a conviction does not necessarily mean that your application will be automatically disqualified from employment consideration.)

Are you currently on felony probation, felony deferred adjudication, or parole? DYes DNo

Have you ever been convicted, placed on deferred adjudication or community supervision, or pleaded guilty or no contest to a

felony offense? DYes DNo Date(s):

Have you ever been convicted, placed on deferred adjudication or community supervision, or pleaded guilty or no contest to a

misdemeanor offense other than a traffic violation? DYes DNo Date(s): -------------

If you answer "Yes" to any of the above 3 questions, please explain in detail on Page 6 (Supplemental Conviction Information) of this application, with the dates and nature of each offense, the name and location of each court, and the disposition of each case. You must include any DUI/DWI offenses.

City of Waco Employment Application Rev 5/2010

Education

Please indicate highest level of education completed: D7 D8 D9 D10 D11 D12 D13 D14 D15 D16 D17 D18 D19+

Did you graduate from high school or receive a GED? DYes DNo

Type of school:

Undergradute Colleges or Universities

Graduate Schools

Technical, Vocational, or Business Schools

Name & Location Dates Attended (From /To)

Name of high school: -------------

Date Graduated

Degree Type

Major/ Minor

Hours Completed

*If you need additional space to list your education history, attach a sheet providing the same information requested above.

If Certification, Registration or Special License is required for the position, please complete the following:

License/Certification

Computer Skills

Date Issued Issued

Date Expires Expires

Issued by/ Location of Issuing Authority

License Number

Computer Skills: DWindows DWord DExcel DOutlook DAccess Other -----------------

Machines or Equipment Operated --------------------------------

Driver's License or ID & Driving Record Information

State Issued __ _ Number ________ __ Class Expiration ___ _ Commercial? DYes DNo

*Please list and give date(s) of every moving violation and/or traffic accident in the last three (3) years (report any DWI-DUI's under criminal history area).

Incident Location Date

Other Skms

Please list any additional training, technical skills or professional knowledge that would support your application.

City of Waco Employment Application Rev 5/2010 2

Employment History This information will be the official record of your employment history and must accurately reflect all significant duties performed. Include all employment for the past ten (1 0) years as well plus military experience and any other relevant experience beyond ten years. Begin with your current or most recent job. Employment history should include each position held, even those with the same employer. Do not use the comment "See Resume". If you need additional space to adequately describe your employment history, you may use this employment history sheet or attach additional employment history sheets providing the same information requested on this application form. This information will be used to determine if you meet minimum work related experience for the position you are applying for.

Job Title ---------------- Employer -------------------

Supervisor's Phone Number ----------Supervisor's Name & Title -------------

Average Number of Hours Worked Per Week --------- Final Salary --------------

EmployerAddress -------------------------------------Number, Street, City, State, Zip Code

Starting Date Ending Date Number of Employees You Supervised ------

Specific Reason for Leaving or Wanting to Leave --------------------------

May we contact this employer? DYes DNo

Summary of Job Duties and Responsibilities:

Job Title ---------------- Employer ------------------


Average Number of Hours Worked Per Week --------- Final Salary -------------

Employer Address---------------------------------------Number, Street, City, State, Zip Code

Starting Date Ending Date Number of Employees You Supervised -----





Employment History - continued

Job Title --------------- Employer ------------------



Employer Address-------------------------------------Number, Street, City, State, Zip Code





Job Title ---------------- Employer ------------------



Employer Address-------------------------------------Number, Street, City, State, Zip Code






Employment History - continued

Job Title ---------------- Employer -------------------


Average Number of Hours Worked Per Week --------- Final Salary -------------

EmployerAddress -------------------------------------Number, Street, City, State, Zip Code

Starting Date Ending Date Number of Employees You Supervised _____ _


May we contact this employer? DYes ONo


Personal References (Not former employers or relatives; should be familiar with your qualifications for employment.)

Name and Occupation Address Phone Number

Please Read Before Signing I certify that all information in this application is true and correct. I understand and agree that any false information, misrepresentation, or concealment of fact is sufficient grounds for either my immediate discharge without recourse, or refusal of employment by the City of Waco.

I understand and agree that all information in this application may be verified by the City of Waco. I also understand that any employment is subject to a satisfactory check of references, and that once a contingent offer of employment is made, I must satisfactorily pass a pre-placement physical, which will include drug and alcohol tests.

I authorize all individuals and organizations named or referenced to in this application, or given otherwise by me as references, to give the City of Waco all information relative to my employment, work habits, and character. I authorize the City of Waco to verify and investigate the status of my driver's license and to conduct any background check it deems necessary, including review of criminal history records. I release any individuals and organizations contacted, and the City of Waco.

I understand that this is not an employment agreement between the City of Waco and the applicant.

Applicant Signature Date


Supplemental Conviction Information Please use this space to list any conviction, probation or deferred adjudication information as requested on Page 2 of this application. Include date, nature of the offense, the name and location of each court and the disposition of each case. If more space is needed, please attach additional sheets in the same format.

Applicant Name ---------------------- Social Security Number -------

Last, First, Middle Initial

Dates (Month/Year) ------- DFelony DMisdemeanor Nature of Offense -----------

Case Disposition -------------------------------

Name and Location of Court ----------------------------

Dates (Month/Year) ------- DFelony DMisdemeanor Nature of Offense -----------



Dates (Month/Year) ------- OFelony DMisdemeanor Nature of Offense -----------



To the Applicant- For Equal Opportunity Employment Purposes: Your completion of the section below is voluntary; refusing to complete this section will not affect the evaluation of your application. The commitment of the City of Waco to a policy of equal employment opportunity requires that certain information be gathered and maintained for government record-keeping requirements only. This section will be detached from your application. The information will not be used for making interviewing or hiring decisions.

Position applied for ----------------- Requisition Number -----------

Race, please check one DWhite/Non-Hispanic DBiack/Non-Hispanic

DAsian/Pacific Islander DAmerican Indian/Alaskan Native

Please tell us how you heard about this position:

OCity of Waco Website OCity of Waco Telephone Job Line

OWaco City Cable Channel (WCCC-TV) DTML Website

DHispanic DOther/Unknown

OCity of Waco Employee

DWaco Tribune-Herald

DOther Internet Job Listing

0 KWTX Channel 10 Jobsite

DTexas Workforce Commission

OCollege/University Career Services

OPrivate EmploymentAgency

DWalk-ln

OJob Fair

Dlibrary

*Please note that to use this form for more than one position, you may save it to your computer.

*TO SUBMIT BY EMAIL: Save application to your computer then attach to email using your email service. Email to: [email protected]

Print


Updated 03/05/2013

PERSONAL HISTORY STATEMENT FOR

Name of Applicant

WACO FIRE DEPARTMENT 10 16 Columbus A venue

Waco, Texas 76701

05 0.13 PERSONAL HISTORY STATEMENT mdl

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NAME OF APPLICANT: _________________ _

DATE: ___ ___;/ ___ ____:/ ____ _

Directions: In the space below, address a letter to Fire Chief John D. Johnston explaining the reasons you would be a better employee over another applicant with similar qualifications. Do not use more space than that provided.

Signature

Updated 03/05/2013 05 0.13 PERSONAL HISTORY STATEMENT mdl

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GENERAL INFORMATION

City of Waco Fire Department Fire Fighter Application Personal History Statement

Date: ___ / ___ _c/ ____ _

Last Name: First Name: Middle/Maiden: -------- ------- ------

Current Residence Address: ---------------------------

City: _________ State: __________ Zip Code: ______ _

Mailing Address if Different: _______________________ _

Residence Telephone Number: (___) __ -___ Cell Phone Number: (___) __ -__ _

Height: __ ' __ " Weight: ___ lbs. Hair Color: ______ Eye Color: ___ _

Date of Birth: I I -----month I day I year

Place of Birth: City: _______ County: _______ State: _______ _

Describe any tattoos, scars, or other distinguishing marks: _____________ _

Do you have a birth certificate? __ Is it recorded? ___ Where recorded? ______ _

Social Security No: Drivers License No: State: ---------- ------- ---

Nearest Relative: Name: _____________ Relationship: _______ _

Address: __________________ Telephone No: (___) __ - ___ _

Emergency Notification: Name: ______________________ _

Address: -------------------------------

Home Phone No:(~_~) Work Phone No: (_~) ______ _

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MARITAL STATUS HISTORY

Spouse Name: _____________ Date of Birth: ____ 1 __ _;1 ___ _ month I day I year

Spouse Maiden Name (if applicable): ____________________ _

Number of Children: ----

Names of Children: Date of Birth: -------------' I I month I day I year

Date of Birth: I I month I day I year

Date of Birth: I I month I day I year

Marital Status: Single: _____ _ Married: Divorced:

How many times have you been divorced? ________ _

If divorced, give date(s) of divorce, place, and court:

Previous Marriage(s): Name: _____________ Date(s): _______ _

Current Address: -~~~------~~~----------------

(Street) (Apt. #)

-,-----,------,---------------,------,-----Telephone No: (__J __ -__ _ (City) (State) (Zip Code)

Have you ever been ordered by a court to pay child support? Yes_ No __ Amount: $ ___ _

Have you ever been delinquent in child support? Yes __ No __

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RELATIVE HISTORY


Even if a relative is deceased, give all information requested and indicate last residence and year of death.

Fmher: ________________________________ ~~~-----------------------------(Full Name) (Age) (Address) (Phone No.)

Mother: ------------------------------------------------------------------

Brothers and Sisters: ---------------------------------------------------------

EDUCATIONAL HISTORY

High School(s) Attended:---------------------------(NAME) (CITY) (STATE) (DATES ATTENDED)

High School Diploma: __ Yes _No G.E.D. Yes No Date Earned I I month I day I year

List information below for all colleges, universities, trade schools, etc. attended. Attach transcripts of all institutions attended with other required documentation.

Name of Institution Attended Dates Attended Credit Degree Year Earned From To Hours Received

Received

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RESIDENCE HISTORY


Beginning with your present address, list all addresses where you have lived during the past 5 years. List by morith and year.

From To Address (Street, City, State, Zip Code)

EMPLOYMENT HISTORY

Beginning with your present or most recent job, list all employment for the past 10 years, including part-time, temporary, or seasonal. Include all periods of unemployment to include school or military. Information shall include street address, city, state, zip codes, and telephone numbers.

From: __ / __ / ___ To: __ / __ / ___ Employer: __________ _

Street Address: -----------------------------

------------------------- l__j __ -___ _ City State Zip Code Company Telephone No.

Job Title: ___________ Job Duties: _______________ _

Full Time __ Part Time __ Temporary __ Voluntary __ Seasonal __ Unemployed __

Name and Title of Immediate Supervisor: ___________________ _

Reason(s) for Leaving:---------------------------


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From: __ I __ ! ___ To: __ / __ / ___ Employer: __________ _

Street Address: -----------------------------

------------------------- l__j ___ -___ __ City State Zip Code Company Telephone No.

Job Title: Job Duties: ----------- ----------------



Reason(s) for Leaving:---------------------------

From: ___ / ___ / ___ To: __ / __ / ___ Employer: __________ _

Street Address: -------------------------------

------------------------- l__j ___ -_____ _ City State Zip Code Company Telephone No.

Job Title: Job Duties: ----------- -----------------



Reason(s) for Leaving:--------------------------


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From: __ / __ / ___ To: __ / __ / ___ Employer: __________ _

Street Address: --------------------------------





Reason(s) for Leaving: __________________________ _

From: __ ! __ / ___ To: __ / __ / ___ Employer: __________ _

Street Address: --------------------------------

---------------------------- l__j __ -___ _ City State Zip Code Company Telephone No.



Name and Title ofimmediate Supervisor: ___________________ _


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From: __ / __ / ___ To: __ / __ / ___ Employer: __________ _

Street Address: --------------------------------------------------

------------------------------------------------- l__j __ -___ __ City State Zip Code Company Telephone No.

Job Title: Job Duties: ----------- -------------------------------

Full Time ___ Part Time ___ Temporary ___ Voluntary ___ Seasonal __ Unemployed __ _

Name and Title of Immediate Supervisor:--------------------------------------

Reason(s) for Leaving: --------------------------------------------------

From: __ / ___ / ____ To: __ / __ / ____ Employer: ___________ _

Street Address: --------------------------------------------------------

------------------------------------------------- l__j ___ -___ __ City State Zip Code Company Telephone No.

Job Title: Job Duties: ----------- -------------------------------

Full Time __ Part Time ___ Temporary ___ Voluntary ___ Seasonal __ Unemployed __ _

Name and Title oflmmediate Supervisor:--------------------------------------

Reason(s) for Leaving: --------------------------------------------------

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From:


__ / __ / ___ To: __ / __ / ___ Employer: __________ _

Street Address: -----------------------------




Name and Title oflmmediate Supervisor: ___________________ _

From: __ / __ / ___ To: __ / __ / ___ Employer: __________ _

Street Address:-----------------------------

------------------------ l__j __ -___ _ City State Zip Code Company Telephone No.



Name and Title oflmmediate Supervisor: ___________________ _



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From: __ / __ / ___ To: __ / __ / ___ Employer: ___________ _

Street Address: --------------------------------

------------------------- (_) __ -___ _ City State Zip Code Company Telephone No.

Job Title: Job Duties: ------------- ------------------


Name and Title of Immediate Supervisor: -----------------------------------------

Reason(s) for Leaving: ------------------------------------------------------

Did you knowingly or intentionally omit or not list any previous employment information for the past 10 years? __ Yes __ No

If yes, provide details such as employer, address, immediate supervisor, termination date, and reason(s) for termination. ---------------------------------------------------

Have you ever been dismissed or asked to resign from any employment or position? _Yes _No If yes, provide details such as employer, address, immediate supervisor, termination date, and reason( s) for termination. -----------------------------------------------------


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Have you ever resigned from a job to avoid being fired? __ Yes __ No

Are you eligible for rehire on all previous jobs? __ Yes __ No

Was each of your past employers given proper notice before you left his/her employment? ---

How many times were you tardy during the last two years? ______________ _

Have you ever given false information to obtain a position or job? ____________ _

Have you ever held a Government Security Clearance? __ Yes __ No

Have you ever violated a Government Security Clearance? Yes No -- --

Have you ever caused anyone to believe that you were acting in the official capacity as a fire fighter when you were not a fire fighter? __ Yes __ No

FIRE DEPARTMENT/ EMS HISTORY

Texas Commission on Fire Protection PIN # _________ Exp. Date __ / __ / __ _

List academy or institution and address where you received your basic fire fighter certificate:

Department of State Health Services I.D. # _________ Exp. Date __ / __ / __ _

List school or institution where your received you EMT training and certificate.

Have you ever applied for employment with the Waco Fire Department? __ Yes __ No If yes, complete below:

Date: I I Results: ---~ ----month I day I year

------------------------------

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Have you ever applied for any other fire department or emergency medical services provider which shall include volunteer or paid? Yes __ No __ If yes, complete below:

Month/Day/Year Fire Department/EMS Provider Status (application on file, tested, failed, etc.)

If you have ever worked for a fire department or emergency medical services provider (include voluntary or paid), list all oral or written reprimands, suspensions, or other disciplinary actions taken against you.

Fire Department/EMS Provider Month/Day/Year Action Taken

Have you ever intentionally falsified any type of fire report or document? __ Yes __ No

MILITARY HISTORY

Have you ever served in the United States Armed Forces? __ Yes __ No


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List all dates of all periods of military service (indicate active or reserve) to include the following:

Branch Periods Rank at Discharge Highest Rank Held

Have you ever received any discharge, other than an honorable discharge (i.e. general discharge under honorable conditions or bad conduct discharge), from any branch of the service? If yes, provide an explanation below.

Has your type of discharge or separation ever been corrected or changed? If yes, give explanation.

Have you ever been refused entry into military service? If yes, provide a detailed explanation below.

SPECIAL QUALIFICATIONS OR SKILLS

Are you fluent in a foreign language or sign language? __ Yes __ No If yes, indicate in each area below your degree of fluency (excellent, good, fair):

Language Reading Writing Speaking Understanding


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List all organizations, societies, clubs, and associations in which you are a member. Include addresses of each one listed:

List any special training, skills, or education you have received related to fire or EMS services:

DRIVING AND CRIMINAL HISTORY

Current Drivers License #: State of Issue Exp. Date __ / __ / __ _ month I day I year

Has your driver's license or privilege to drive in any state or country ever been: Refused Issuance or Renewal? Yes No Suspended? __ Yes __ No Revoked? Yes No

If you answered yes to any above question, list the details below: Date Location Reason

__ / __ ! __ _ month I day I year

__ ! __ ! __ _ month I day I year

List all moving and non-moving traffic tickets (excluding parking tickets) that you have received in the last three (3) years.: List the disposition of each (i.e., paid fine, defensive driving, probation, deferred adjudication, dismissed, etc.)

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List all of the accidents you have been involved in as a driver in the past three (3) years whether reported or not reported:

Date Location Explanation of Event I I -------

month I day I year

I I -------month I day I year

Have you ever been fingerprinted by any law enforcement agency? __ Yes __ No If yes, please give a brief, specific description of the event:

Have you ever been charged with a misdemeanor? __ Yes __ No If yes, please give a brief, specific description of the event:

Have you ever been charged with a felony? __ Yes __ No If yes, give specific details of the event:

Have you ever been a member of any organization that advocates the overthrow of our constitutional form of government? __ Yes __ No If yes, give specific details:

Do you belong or have you ever belonged to any organization that advocates discriminatory racial or religious practices? __ Yes __ No If yes, give specific details:


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FINANCIAL AND CREDIT HISTORY

What is your present gross monthly income? $ _____ _

What is your spouse's gross monthly income? $ _____ _

List and identify other sources of monthly income

$ _____ _

Net monthly income $ _____ _

List any and all accounts or property that were repossessed or charged off:

Account/Property Date __ ! __ ! __ _ __ / __ ! __

I I -------

Explanation

Have you ever written any checks that were returned for insufficient funds or been notified by a bank that your account was overdrawn? Yes No If yes, give a brief description including approximate amount and name of financial institution(s):

When we check your credit history with a credit bureau, how do you think the report will appear?

Excellent Good Fair Poor

Why? ________________________________ _


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What do you consider your current financial condition to be?

Excellent Good Fair Poor

Why? _______________________________________________________________ _

Have you ever been refused credit? __ Yes __ No Ifyes,pleaseexplcin: ____________________________________________________ _

In the past five (5) years, have you filed for bankruptcy? __ Yes __ No

CHARACTER REFERENCE HISTORY

List five (5) persons who have known you for a minimum of two (2) years and who have knowledge of you and your qualifications. Do not include relatives, current City of Waco employees, or former employers.

N arne Years Known ------------------------------------------- -------

Address--------------------------------------------- Zip Code __________ _

Employer Address------------------------------------- Zip Code _______ _

Residence Telephone # (__J __ - ___ _ Business Telephone # l__) __ - ____ _

Name YearsKnown ------------------------------------------- -------

Address--------------------------------------------- Zip Code __________ _

Employer Address------------------------------------ Zip Code _____ _

Residence Telephone # l__) __ - __ _ Business Telephone # (__J __ - __ __


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Nmne YeMsKnown ---------------------------------------- ------------

Address----------------------------------------- Zip Code _____ __

Employer Address------------------------------------ Zip Code _______ _

Residence Telephone # (____) ___ - ___ _ Business Telephone # (__J ___ - ____ _

Nmne YeMsKnown ---------------------------------------- -----------

Address---------------------------------------- Zip Code _____ _

Employer Address ----------------------------------Zip Code ________ _

Residence Telephone # (____) ___ - ____ _ Business Telephone # (____) ___ - ____ _

Nmne YeMs Known ---------------------------------------- -----------

Address---------------------------------------- Zip Code _____ __

Employer Address -----------------------------------Zip Code _______ _

Residence Telephone # (____) ___ - ___ _ Business Telephone # (____) ___ ------


Page 17 of21


ALCOHOL AND DRUG USE HISTORY

Describe in your own words your use of alcoholic beverages:

Have you ever been treated for alcohol addiction? __ Yes __ No If yes, describe where, when and for how long including the number of treatment experiences:

Have you ever participated in or completed a drug/alcohol rehabilitation program? __ Yes __ No If yes, state where, when, and for how long including the number of program occurrences:

Have you ever in any way been involved with, sold, experimented with, or provided any of the following illegal drugs?

Marijuana Yes No Peyote Yes No Hashish Yes No Mushroom Yes No Speed Yes No Codeine Yes No Heroin Yes No Tranquilizer Yes No L. S. D. (Acid) __ Yes __ No Amphetamine __ Yes __ No Cocaine Yes No Barbiturates Yes No Crack Cocaine Yes No Designer Drugs __ Y es __ No P. C. P. Yes No Steroids Yes No Ecstasy (XTC) __ Yes __ No Inhalants Yes No Morphine Yes No Second Hand High Yes No Prescription Drugs not prescribed to you by a Physician Yes No


Page 18 of21


If you have answered yes to any of the above illegal drugs questions, please explain below:

Drug Number of Times Used ------------------------ ------------------

Nature of Use or Involvement -----------------------------------------

Last Time Used or Involved Form of Substance ----------- ------------------

Drug Number ofTimes Used ------------------------ ------------------


Last Time Used or Involved Form of Substance ----------- ------------------

Drug Number of Times Used ------------------------ ------------------


Last Time Used or Involved Form of Substance: ----------- -----------------------

Are you presently using any OTC (over-the-counter) medicine or drugs prescribed by a physician at this time? Yes No. Ifyes, please give a description: ____________________ _

MISCELLANEOUS STATEMENTS/ QUESTIONS

As an applicant for a position with the Waco Fire Department, you will be asked to take a polygraph examination. Is there any reason you would refuse to take a polygraph examination?

Yes No

Have you ever taken a polygraph examination? ____ Yes ____ No Describe the circumstances: --------------------------------------------------

Reviewed 03/05113 06 0.13 COW PHS 1 Packet 2 MDL

Page 19 of21


Your work requires working weekends, rotating shifts, overtime, long hours, and arduous tasks. Provide specifics if this will be a problem for you: ________________ _

Have you ever witnessed a theft while at work and not reported it to a supervisor? Yes No

Have you discussed this employment opportunity with your spouse and/or family? Yes No

Does your spouse or family support you in seeking this career? Yes No

Do you expect any family problems as a result of this career? Yes No

Do you sincerely seek a long-term career with this department? Yes No


Page 20 of21


I hereby certify to the best of my knowledge and belief that there are no willful misrepresentations, omissions, or falsifications on this application. In order for the City of Waco to be fully informed as to my personal character and qualifications for employment, I refer to each of my former employers and to any other person who may have information concerning me.

As this information is furnished at my express request and for my benefit, I do hereby release officials of the City of Waco from any and all liability for any damage of whatsoever nature on account of furnishing such information.

I also acknowledge that any misrepresentations, falsifications, or inaccuracies made in answering the questions in this application is good cause for removal from the eligibility list or discharge during or after a period of probation.

Print Name: -----------------------------------------------

Signature of Applicant: ---------------------------------------

Subscribed and sworn to before me this _____ day of _____________ , 20 _____ __

Reviewed 03/05/13 06 0.13 COW PHS! Packet2MDL

Notary Public in and for the State of Texas

My Commission Expires: __ / __ / __ month I day I year

Page 21 of21

Authorization to Release of Personal Information to the Waco Fire Department

I, , do hereby authorize a review, full disclosure and release of any records concerning the Waco Fire Department, whether the said records are of public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure and release of the records of education institutions, financial or credit institutions. This includes records of loans, records of commercial or retail credit agencies (including credit reports and or ratings), and other financial statements and records wherever filed. This is also to include U. S. Veteran Administration records, employment and pre-employment records, including salary and benefit files, background reports, efficiency ratings, complaints or grievances filed by or against me; as well as all records and recollections of attorney-at-law, or other counsel, whether representing me or another person in any case, either civil or criminal, in which I personally have or have had an interest.

I understand that any information obtained by a personal history background investigation that is developed either directly or indirectly, in whole or in part, resultant from this, will be considered in determining my suitability for employment by the Waco Fire Department. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for releasing and/or disclosure of such information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information.

I further agree to waive any right whatsoever to the background investigation report, polygraph report, or any other report developed through this waiver.

A photocopy of this release form will be valid as an original thereof, even though the said copy does not contain any original writing of my signature. This authorization and waiver shall not be valid after one ( 1) year from the date signed.

Signature Address (City, State, Zip Code)

--------------~/ I ----Date of Birth month I day I year Social Security Number

Subscribed and sworn to before me, the undersigned authority, this_ day of ____ , 20 __ _


My Commission Expires: ___ __;/ / ___ _ month I day I year

Reviewed 03/05/2013 09 0.13 WFD App Releasel Packet 5 MDL

CITY OF WACO-- FIRE DEPARTMENT AGILITY TEST -- RELEASE of CLAIMS & WAIVER of LIABILITY

THE STATE OF TEXAS

COUNTY OF McLENNAN

)( )( )(

KNOW ALL MEN BY THESE PRESENTS:

I, , for and in consideration of being considered for employment by the Waco Fire Department, do hereby make the following representations and acknowledgements:

1. As a part of the application process, I will have to take a physical agility test. The test may involve running, lifting, climbing, and carrying. Whether I am in good physical condition or poor physical condition, I recognize that there are risks of injury involved in taking this agility test. I further understand that if I am not in good or adequate physical condition, or ifl have any pre-existing injuries, diseases, or physical conditions which may be aggravated by this test, I may be placing myself at risk. I fully accept all risk and responsibility involved in engaging in this agility test.

2. I realize and agree that when taking the agility test, I will not be an agent, servant or employee of the City of Waco or the Waco Fire Department, and therefore will not be covered by any worker's compensation, death, or disability benefits of the City of Waco.

By signing this waiver, I do hereby release and forever discharge the City of Waco, the Waco Fire Department, and its elected officials, officers, and employees, in both their public and private capacities, from any and all liability, claims, suits, demands or causes of action which may arise from my taking the agility test. This waiver is intended to cover all acts or omissions ofthe City of Waco, the Waco Fire Department, and its elected officials, officers, and employees, regardless of whether such act or omission is the result of an intentional, reckless, grossly negligent, or negligent act. By signing this waiver, it is my intent to bind my heirs, executors, administrators and assigns. I understand the terms of this release are contractual and not a mere recital. Before signing this release, I read it fully and hereby acknowledge that I understand it. I have signed this document of my own free will.

Home: (__J ________ _ Signature:

Work: (__J ________ _ Print Name:

Address:

SWORN TO AND SUBSCRIBED before me this ____ day of __________ , 20 ___ _


In case of emergency, notify (please print):

Name:

Address: Home:(_) __________ Work: (__) _______ _

Relationship to me: ___________________ _

Reviewed 03/05/2013 08 0.13 AGILITY RELEASE MDL

CITY OF WACO

WACO FIRE DEPARTMENT CHIEF JOHN D. JOHNSTON 1016 COLUMBUS AVENUE

WACO, TEXAS 76701 254-750-1740

Applicant: IMPORTANT - Read Carefully Before Signing -Return completed Polygraph Data Sheet with your Application

The application process for the City of Waco Fire Department includes a polygraph examination. It will be used to verify information provided by you, to develop new information about you that has not been previously screened, and to clarify any questionable or incomplete information.

Polygraph results are based on the analysis of your physiological responses. Prior to the examination, the examiner will explain the testing procedure and will inform you of every question that is going to be asked during the procedure.

It is of utmost importance that you are completely truthful in your answers to the attached questions and to the examiner. The examination questions will be a combination of the information you provided on your Personal History Statement, your answers to the attached polygraph questions, as well as the information you will discuss with the examiner prior to the actual polygraph examination.

The majority of the answers will be yes or no. In many instances you will want to give explanations, especially if you answer yes to any question. When you arrive to take the polygraph, you will have ample time to explain details of your answers during talks with the officer who is assigned to conduct the polygraph.

Note: Any willful misrepresentations, omissions, or falsifications can

cause you to be eliminated from the selection process. Answer all the questions even if they are vaguely related to you or associated with

you in any way.

Name of Applicant (Please Print):

Last First Middle Maiden

Social Security#: __ -__ -___ Date of Birth: __ / __ / __ Age. __ _ month I day I year

Reviewed 03/05/2013 07 0.13 Polygraph Section MDL

Page 1 of 13

POLYGRAPH SECTION

1. Have you ever taken a polygraph examination before? If yes, how many times? ________ _

2. Did you complete your application and all other required documents requested as accurately and as completely as possible at the time you filled them out?

3. Have you deliberately falsified or withheld any information requested?

4. Did you include all past employers that were requested?

5. Have you ever walked off a job or quit without giving requested or required notice?

6. Have you ever been fired from a job?

7. Have you ever been asked to resign a position?

8. Have you ever quit or resigned a position rather than be fired or forcibly terminated for cause?


Page 2 of 13

Circle Yes or No

y N

y N

y N

y N

y N

y N

y N

y N

9. Did you give the real reasons on your Personal History Statement for leaving the former employers that you listed?

10. Are there any of your past employers who would give you a poor employment reference based on performance?

11. Have you ever for any reason filed a lawsuit or administrative claim against a former employer for any reason?

12. Have you ever forged another person's signature on a check or other document with the purpose to defraud anyone?

13. Have you ever illegally used a credit card?

14. Have you ever deliberately and knowingly falsified any record, report, or document for your own personal gain or to defraud anyone?

15. Have you ever been involved in any fraudulent stock, bond, or securities transactions?

16. Have you ever falsified any payroll records or time cards?

17. Have you ever falsified or manipulated any medical records or documents?

Reviewed 03/05/20 13 07 0.13 Polygraph Section MDL

Page 3 of 13

y N

y N

y N

y N

y N

y N

y N

y N

y N

18. Have you ever transported, concealed, or had any illegal involvement with: Illegal Aliens Stolen Vehicles Prostitutes Illegal Automobile or Aircraft Parts Child Pornography Alcohol/ Tobacco/ Narcotics Narcotic Paraphernalia or Chemicals Hazardous Materials or Chemicals Other types of Contraband

19. Have you ever used an inhalant, paint, glue, thinner, or other petroleum product illegally?

20. Have you ever had any wage or tax garnishments in the past for any reason?

21. Were you ever arrested as a juvenile?

Reason? Disposition?

22. Have you ever been arrested as an adult?

Reason? Disposition?

23. Have you ever been detained, questioned, or interrogated by any police or military agency?

24. Have you ever been a subject in any type of work related investigations involving yourself?

25. Have you ever been offered a bribe or payoff?


Page 4 of 13

y N y N y N y N y N y N y N y N y N

y N

y N

y N

y N

y N

y N

y N

26. Have you ever solicited or accepted a bribe?

27. Are you currently or have you ever been associated in any way with organized criminal conduct?

28. Have you ever filed for and/or received any money or benefit from a false insurance claim?

29. Have you ever cheated on your federal income taxes?

30. Have you ever falsified an expense account?

31. Have you ever sold, experimented with, provided, or in any way been associated with any of the following illegal drugs?

Type of Drug Marijuana Hashish Cocaine Crack Speed Heroin Acid Morphine Codeine Mushrooms Tranquilizers Peyote Amphetamine Barbiturates Designer Drugs Steroids Inhalants Non-prescribed Prescriptions Others


Last Time Used

Page 5 of 13

y N

y N

y N

y N

y N

y N

32. Have you ever used another person's prescription medication?

33. Have you ever abused your personal prescription medication?

34. Have you ever transported or made the arrangements for the illegal sale or transfer of any illegal drug, narcotic, or marijuana?

35. Have you ever worked under the influence of any drug, narcotic, or marijuana?

36. Have you ever had any illegal drug, narcotic, or marijuana with you at your worksite for any reason?

3 7. Has any illegal drug, narcotic, or marijuana use ever interfered with your work in any way including being late to work or unable to work?

38. Have you ever been evicted or forcefully removed from any place where you have lived?

39. Do you have any close friends or relatives who have criminal records?

40. Do you have any close friends or relatives actively involved in any criminal activity or enterprise?


Page 6 of 13

y N

y N

y N

y N

y N

y N

y N

y N

y N

41. Do any of your close friends or relatives regularly use any illegal drugs, narcotics, or marijuana?

42. Have you ever been in possession of any illegal explosives or detonation devices?

43. Have you ever been involved in any subversive or terroristic activities or affiliations?

44. Have you ever committed an act of sabotage or espionage?

45. Do you advocate the overthrow of the present system of government in this state or the United States?

46. Have you ever been rejected for employment by any fire department agency in the past?

4 7. Have you ever removed or altered the serial numbers or identification marks from any property?

48. Have you ever stolen the services of a utility company, cable, or satellite provider?


Page 7 of 13

y N

y N

y N

y N

y N

y N

y N

y N

49. Have you ever obtained unemployment, welfare funds, or food stamps illegally?

50. Have you ever been a member or solicitor of an illegal organization or gang?

51. Have you ever lied under oath in a deposition or in court?

52. Have you ever falsified a Notary oath?

53. Have you ever used any unauthorized postage, long distance, or copying in the workplace or any other circumstances?

54. Have you ever possessed, transported, sold, held or manufactured:

55.

Automatic Weapons Explosives or Explosive Devices Illegal Firearms Incendiary Devices Hazardous Material or Chemicals

Have you ever been in military service? Branch Served: _______ Highest Rank: _____ _ Dates Served: to -------- ------------Type ofDischarge: _________________ _ Security Clearance: __________________ _ Court Marshal: --------------------Article 15: -----------------------


Page 8 of 13

y N

y N

y N

y N

y N

y N y N y N y N y N

y N

56. Have you ever stolen or not returned any property during any military service?

57. Did you supervise others while serving in the military?

58. Have you ever been disciplined by an employer in the past for failure to follow orders or policies?

59. Have you ever released any confidential information to any unauthorized person?

60. Can you be employed as a fire fighter and maintain confidentiality?

61. Is there anything in your Personal History Statement that, if investigated, would be harmful or detrimental to you or to the department?

62. Have you ever forged a prescription for drugs or knowingly delivered a forged prescription for drugs?

63. Have you been a patient in a drug or alcohol rehabilitation program?

64. Have you ever completed a drug or alcohol rehabilitation program?


Page 9 ofl3

y N

y N

y N

y N

y N

y N

y N

y N

y N

65. Have you ever falsified a blood or urine test for drugs?

66. Have you ever stopped payment on a check so as to defraud someone?

67. Have you ever been fingerprinted for any reason?

68. Have you ever made a false bomb threat?

69. Have you ever tried to extort someone else?

70. Have you ever been convicted of a felony or other serious crime?

71. Are you currently on probation, parole, or out of jail on bond or awaiting appeal on a felony conviction?

72. Do you have any criminal or civil court case(s) now pending against you for any reason?

73. Have you ever had any repossession or collection action(s) against you?

74. Have you ever had any legal judgements or other garnishments issued against you?


Page 10 of 13

y N

y N

y N

y N

y N

y N

y N

y N

y N

y N

75. Are you presently wanted by any police or military branch for any criminal reason you are aware of?

76. Have you ever committed any major crime?

77. Do you have a regular habit of gambling or betting?

78. Do you have any outstanding gambling debts?

79. Have you ever been investigated by law enforcement or military agency for any reason that you are aware of?

80. Could your employment with the department be harmful or detrimental to the department in any pre-planned way?

81. Are you currently or have you ever been a member or a sympathizer of any subversive, revolutionary, or terrorist organization, group, or ideology?

82. How would you describe your alcohol consumption habit? None Special Occasions ________ _ Weekends Daily _______ _ No Regularity ___________ _

83. Have you ever been treated for alcohol or drug abuse?


Page 11 of 13

y N

y N

y N

y N

y N

y N

y N

y N

84. Have you ever purchased alcohol for or provided alcohol to anyone under legal age?

85. Have you ever secretly consumed alcohol at your workplace?

86. Do you feel that you may have ever had a drinking problem?

87. Have you ever been late to work, unable to work, or has alcoholic beverage use ever interfered with your work in any way?

88. Have you ever knowingly or intentionally written any bad checks to defraud anyone?

89. Have you ever communicated to your supervisor that you were sick within the past year when you were actually not ill and could have and should have reported for work?

90. Have you ever called in sick to any employer so you could take a written test for any fire department?

91. Have you ever called in sick to any employer so you could take a physical agility test for any fire department?

92. Have you ever intentionally started or maliciously caused a fire?


Page 12 of 13

y N

y N

y N

y N

y N

y N

y N

y N

y N

93. Do you currently have or have you ever had a driver license in any other state?

94. Are you a citizen ofthe United States?

95. Have you ever worked under another name or used an alias?

96. Have you ever cheated on any examinations while attending a fire or EMS academy?

97. Have you ever been suspended or expelled from any school?

98. Have you ever been involved in any fistfights or shoving matches?

99. Have you ever used a weapon in a fight?

100. Have you ever witnessed a theft while at work and not reported it to a supervisor?

y N

y N

y N

y N

y N

y N

y N

y N

101. Have you answered all questions truthfully and to the best of your ability? y N

Signature: _____________________ _ Date I I -------month I day I year


Page 13 of 13

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