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Personal History Statement Instructions

Personal History Statement Instructions
IMPORTANT INSTRUCTIONS
Use the tabs at the top of each page or use the Previous and Next buttons at the bottom of each page to navigate to sections.
There are many fields on this form and you may not have all information available at the time you begin and THIS FORM WILL TIME OUT AFTER A PERIOD OF INACTIVITY.
You are encouraged to use the button at the bottom of each page to save an incomplete form. When saving, enter a valid email address that you have access to. If you do not receive an email with a link to your incomplete form please check your junk or spam email. If you do not receive the email, stop, do not enter any additional information and contact the CCFD Training Division at 361-826-8423.
A thorough background investigation is required to properly evaluate the suitability of applicants for employment with the Corpus Christi Fire Department. These instructions are provided as a guide to assist you in properly completing your Personal History
Statement. It is essential that the information is accurate in all respects, so please read all instructions carefully before proceeding.
The Personal History Statement will be used as a basis for a background investigation that will determine your eligibility for becoming an employee.
1. Avoid errors by reading the directions carefully before making any entries on the form.
2. You are responsible for obtaining correct and full addresses. If you are not sure of an address, personally verify before making that entry on this history statement. Errors will not be viewed favorably. ALL ADDRESSES MUST BE COMPLETE WITH ZIP CODES.
3. Answer all questions as completely as possible in the space provided.
4. Any supplemental documents should be attached on the last page. An accurate and complete form will help expedite your investigation. Omissions or falsifications may result in disqualification.
5. You are responsible for furnishing any changes and/or updating your application as needed, such as address changes or telephone changes via email to Mallory Cluiss (MalloryC@cctexas.com)
6. DO NOT LEAVE ANY AREA OR QUESTION BLANK. Any candidate submitting an incomplete application MAY NOT BE CONSIDERED FOR EMPLOYMENT. Your application will be evaluated on completeness and neatness.
7. All documents requested must be submitted with the application (photocopies are acceptable in most cases). Required documents vary according to the history of the applicant. If a document cannot be provided please submit a memo with an explanation of what steps were taken to retrieve the required Information and when the document will be available.
NOTE: Military Information & Authorization to Release Information must be notarized by a Notary Public. Only sign these forms in the presence of a Notary Public or they will not be valid. Section 9 is only required if you have prior or current Military Service.
Your completed packet must be submitted before 5:00 p.m. of the date specified at the testing site.
If you have any questions please contact the Assistant Chief of Training at 361-826-3920. Remember the Personal History Statement and all supporting documents are required to conduct your background investigation. Failure to submit a packet and required documents will eliminate you from the application process.

Required Documentation

Required Documentation
The following is a list of documents required to be submitted with your personal history statement. All documentation must be submitted with your personal history statement by the established deadline unless arrangements have been made ahead of time with department staff. If a document cannot be provided please submit a memo explaining why the document cannot be provided, what steps were taken to retrieve the required information, and when the document will be available. If a document does not apply to you, check the N/A section. Any transcripts or documentation that must be submitted manually should be delivered or mailed to the following address:
Corpus Christi Fire Administration
2406 Leopard Street, Suite #300
Corpus Christi, TX 78408

"Active" or "In-force" Court Orders (if any)
Copy of High School Diploma or GED
Official Copy of High School Transcript(s)
Complete Credit Report (Equifax, Experian or TransUnion)
Copy Current Driver License
Copy of Proof of Motor Vehicle Liability Insurance
Copy of Selective Service Registration (males only)
To obtain a copy of your Selective Service Registration visit: https://www.sss.gov/verify/
Copy of College Diploma(s)
Official Copy of College Transcript(s)
Copy of Marriage License(s)
Copy of applicable Training Certificates or Licenses
Copy of DD-214, NG-22 or other (if military service)
Documentation of Up-to-Date Child Support Payments
Copy of Final Divorce Decree(s)
Out of State Driver License (if applicable)
Authorization to Release Information (***Signed & Notarized)
Download Authorization To Release Information prior to completing this application. Click Here
Authorization to Release Information-Military (*** Signed & Notarized)
Download Authorization to Release Information-Military prior to completing this application. Click Here

Additional Instructions

Additional Instructions to the Applicant
The information you provide in the Personal History Statement will be used during the Background Investigation to assist in determining your suitability for an Entry-Level position, in accordance with the Civil Service Rules and Regulation for the State of Texas, the City of Corpus Christi and the Corpus Christi Fire Department.
It is your responsibility to complete this form and provide all required information.
Follow instructions given above providing the completed forms for your background investigation.
Remember attention to detail, depending on your efforts, are judged by the hiring committee. Your efforts will reflect positively or negatively about your character.
***YOU MAY BE DISQUALIFIED FROM PROCESSING FOR OMISSIONS OR FALSE STATEMENTS***.
DISQUALIFICATIONS
There are very few automatic bases for rejection. Even issues of prior misconduct, employee terminations, and arrests are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will result in your application being rejected, regardless of the nature or reason for the misstatements/ omissions. In fact, the number one reason individuals "fail" background investigations is because they deliberately withhold or misrepresent job-relevant information from their prospective employer.
This personal history statement is a governmental document. Be truthful, as there are criminal consequences for lying on a governmental document.
Disclosure of Medically Related Information
In accordance with the U.S. Americans with Disabilities Act and the Genetic Information Non-Discrimination, Applicants are not expected or required to reveal any medical or other disability-related information about themselves in response to questions on this form, or to any other inquiry made prior to receiving a conditional offer of employment.

I have read, understand, and agree to abide by the above instructions.
Signaturefield type signature
Datefield type date
Date will be captured on form submission

Section 1: Personal Information

List the following demographic information as it appears on your formal identification. Please be sure to include some other (alternate) spelling of your name or any other name preferences.

Last Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Middle Namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Suffixfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Other names you have used or been known by (including maiden names, nicknames, birth names, and legally changed names)
×
- Maiden Name, Nickname. Aliasesfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
If more than one alias click "Add" below. To remove an alias line click the "x" to the right.Add
Street Address (Physical Address. Place you actually live)field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Cityfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Statefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Zip Codefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Mailing address is the same as above*field type radio button
Mailing address is the same as aboveYesNo

Email address (List all other email addresses, if any)
×
- Email Address*field type email
If more than one email address click "Add" below. To remove an email address line click the "x" to the right.Add
Are you a US Citizen?*field type radio button
Are you a US Citizen?YesNo
Are you Native Born or Naturalized?*field type radio button
Are you Native Born or Naturalized?NativeNaturalized
Are you a resident alien who is eligible and applied for U.S.Citizenship?*field type radio button
Are you a resident alien who is eligible and applied for U.S.Citizenship?YesNo
Have you ever lived outside of the U.S.?*field type radio button
Have you ever lived outside of the U.S.?YesNo
If you lived outside of the U.S., Where did you live?*field type single line
Input blocked. Maximum character limit of 4000 characters reached.

Place of Birth (City, County, State, Country)

City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
County (e.g. Denton County)*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Country (e.g. U.S.A.)*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date of Birth*field type date
Social Security Number*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Driver License # / State Issued*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Previous Driver License # / State Issuedfield type single line
Input blocked. Maximum character limit of 4000 characters reached.

Physical Description

Height*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Weight*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Hair Color*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Eye Color*field type single line
Input blocked. Maximum character limit of 4000 characters reached.

List and describe all scars, tattoos and other distinguishing marks

	Scars, Tattoos, Other Distinguishing Marks and Locationsfield type single line	Offensive?*field type radio button
Row 1×	Scars, Tattoos, Other Distinguishing Marks and Locationsfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Offensive?*field type radio button Offensive?YesNo	×

If more than one distinguishing mark click "Add" below. To remove a distinguishing mark line click the "x" to the right.Add

Court Orders

Are you subject to any "Active" or "In-force" Court Orders ?*field type radio button
Are you subject to any "Active" or "In-force" Court Orders ?YesNo

Section 1 C: Immediate Relatives
List all immediate relatives (even if deceased). Include father, mother, parent in law, siblings, stepparents, step or half siblings and any other family who lives with you. Also include anyone who lives with you even if not related by blood or law (consanguinity or affinity). (Including roommates, boarders and permanent long term guests)
×
- Is this relative living or deceased?field type radio button
  Is this relative living or deceased?LivingDeceased
- Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Date of Birth*field type date
- Relationship to you*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Primary Contact Phone #*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Alternate Contact Phone #field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Maiden Name (if applicable)field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Occupationfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
If more than one immediate relative click "Add" below. To remove an immediate relative block click the "x" to the right.Add

Section 2: Personal References

Provide four (4) personal references who have known you three (3) or more years. They must know you well enough to provide information about you, in all aspects of your life. Make every attempt to list persons who are not included elsewhere. Do no list: supervisors, co-workers, relatives or other family. List your relationship to each (current friend, former friend, college roommate, Professor, Instructor, client, etc.)

Personal References
×
- Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Primary Contact Phone #*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Alternate Contact Phone #field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Relationship To Youfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Years Known?field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Occupationfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
×
- Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Primary Contact Phone #*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Alternate Contact Phone #field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Relationship To Youfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Years Known?field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Occupationfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
×
- Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Primary Contact Phone #*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Alternate Contact Phone #field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Relationship To Youfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Years Known?field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Occupationfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
×
- Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Primary Contact Phone #*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Alternate Contact Phone #field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Relationship To Youfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Years Known?field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Occupationfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
Add

Section 3: Residences

List all residences during the last five (5) years or since age 17. Starting with the most recent and working backwards. Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit or apartment number). Do not use P.O. Boxes. Additionally, list all states where you have lived (even if more than five (5) years ago).

Residence(s) (current residence first)
×
- Name and street address of residence*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Manager, Landlord, or Owner*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Manager, Landlord, Owner Phonefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Manager, Landlord, Owner Email*field type email
- From (Month/Year)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- To (Month/Year)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Reason for movingfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Paid For By?field type radio button
  Paid For By?SelfSomeone else
- If paid for by someone else, who?*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
If more than one residence click "Add" below. To remove a residence block click the "x" to the right.Add

States

List all states where you have lived (even if more than five (5) years ago). If you lived outside of the USA select "Lived Outside of USA" and enter the country name.

	State where you have lived*field type drop-down	Country Name (Outside of USA)*field type single line
Row 1×	State where you have lived*field type drop-down	Country Name (Outside of USA)*field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one state click "Add" below. To remove a state line click the "x" to the right.Add

Section 5: Employment

LIST All JOBS you have ever held, beginning with your most recent and working backwards to your first job held. Include all jobs, no matter how brief and include part-time, temporary, seasonal, self-employment and volunteer jobs; (as well as military service), In Its proper sequence. If you were UNEMPLOYED at any time, list the dates of unemployment and write "unemployed" In the blank designated for your employer. Make every attempt to provide names, addresses and telephone numbers for the business, supervisors and co-workers.

Employer(s) (most recent first)
×
- Employer*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- May we contact this employer?*field type radio button
  May we contact this employer?YesNo
- Employed / Unemployed From (Month/Year)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Employed / Unemployed To (Month/Year)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Who paid the majority of your expenses?*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- City*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- State*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Zip Code*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Employer Phone*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Job Title*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Salary*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Duties*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Reason for leaving*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Eligible for rehire?*field type radio button
  Eligible for rehire?YesNo
- Primary Supervisor*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Phone*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Secondary Supervisorfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Phonefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Emailfield type email
- Co-Worker*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Phone*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Email*field type email
- Co-Workerfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Phonefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Emailfield type email
- _________________________________________________________________________________________
If more than one employer click "Add" below. To remove a employer block click the "x" to the right.Add

Section 7: Education History

Indicate the highest level of education that you have obtained.*field type radio button
Indicate the highest level of education that you have obtained.Graduate Equivalency DiplomaTrade/Vocational SchoolMaster's DegreeHigh School DiplomaAssociate DegreeDoctorate/Ph.D.Some CollegeBachelor DegreePost-Doctoral WorkCollege Certificate
High School(s) or Home Schools
List all High School(s), (or home schools), that you have attended. Provide dates and locations for each. (No matter how brief).
×
- School Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Location (city/state)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- From (Mo/Yr)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- To (Mo/Yr)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Grad. Date*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- GPA*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- A button to attach Diploma and Transcript(s) is available on the last page.
- _________________________________________________________________________________________
If more than one high school click "Add" below. To remove a high school block click the "x" to the right.Add
School, College, or University
List all colleges, universities or vocational schools you have attended. Provide all information requested below regardless of whether or not you withdrew and did not receive any credits. List the degree(s) achieved at each. ***INCLUDE AN OFFICIAL TRANSCRIPT OR TRANSCRIPTS VERIFYING EACH.
×
- School, College, or University Name/Degree*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Location (city and state)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- From (Mo/Yr)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- To (Mo/Yr)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Grad. Date*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- GPA*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Hours Attempted*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Hours Earned*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- A button to attach Diploma(s) and Transcript(s) is available on the last page.
- _________________________________________________________________________________________
If more than one school click "Add" below. To remove a school block click the "x" to the right.Add
Professional Licenses, Certifications or Credentials
List all Professional Licenses, Certifications or Credentials. (Documents issued by a governmental agency; authorizing you to engage in a profession). [I.e. Firefighter, Paramedic, EMT, Police Officer, Registered Nurse, Plumber, Electrician, Allied Health worker, Teacher, etc.]. ***PROVIDE COPIES OF EACH.
×
- License/Certificate/Credentialfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Licensing Authority/ Agencyfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Date of Issuefield type date
- Date of Expirationfield type date
- A button to attach Professional Licenses, Certifications or Credentials is available on the last page.
If more than one license, certificate, credential click "Add" below. To remove a license, certificate, credential line click the "x" to the right.Add
Have you ever taken a Texas Commission on Fire Protection exam that you failed to pass?*field type radio button
Have you ever taken a Texas Commission on Fire Protection exam that you failed to pass?YesNo
How Many Times?*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Which Certification(s)?*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Have you ever taken a National Registry or State EMS exam that you failed to pass?*field type radio button
Have you ever taken a National Registry or State EMS exam that you failed to pass?YesNo
How Many Times?*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Which Level? (EMT, Paramedic, etc.)*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Have you ever attended a Fire, EMS, Corrections or Police Academy? (Or other public safety academy).*field type radio button
Have you ever attended a Fire, EMS, Corrections or Police Academy? (Or other public safety academy).YesNo
What Type? (Fire, Police, EMS, other)*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Name of Academy?field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Location (City/State)?*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Did you Graduate?*field type radio button
Did you Graduate?YesNo
Graduation Datefield type date
If you did not Graduate, Why?*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Special License or Advanced Training Certificates
List any special license(s) or advanced training certificates that you hold. (I.e. pilot, radio operator, SCUBA, CPR, etc.) Provide copies.
×
- License/certificationfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Licensing authorityfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Date of Issuefield type date
- Date of Expirationfield type date
- A button to attach Professional Licenses, Certifications or Credentials is available on the last page.
- _________________________________________________________________________________________
If more than one special license or advanced training certificate click "Add" below. To remove a license, or training line click the "x" to the right.Add

Languages

List any language(s) in which you are proficient and indicate the degree of proficiency. (Use the terms: excellent, good, fair or poor).Enter ENGLISH in the first line.

	Language*field type single line	Reading*field type drop-down	Writing*field type drop-down	Speaking*field type drop-down
Row 1×	Language*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Reading*field type drop-down	Writing*field type drop-down	Speaking*field type drop-down	×

If more than one language (in addition to English) click "Add" below. To remove a language line click the "x" to the right.Add

Section 8: Education Behavior

Answer "Yes" or "No" to the following questions. If you answer yes to any of the questions, please provide an explanation in the space provided.

1. Have you ever been disciplined, expelled, suspended or placed on probation by an academic institution (including High School)?*field type radio button
1. Have you ever been disciplined, expelled, suspended or placed on probation by an academic institution (including High School)?YesNo
If Yes, give a reason and explain.*field type multi line
2. Have you ever been accused or sanctioned by an academic institution for cheating. plagiarism, hazing or dishonesty?*field type radio button
2. Have you ever been accused or sanctioned by an academic institution for cheating. plagiarism, hazing or dishonesty?YesNo
If Yes, explain.*field type multi line
3. Have you ever had a license, certification or professional credential disciplined, suspended or revoked?*field type radio button
3. Have you ever had a license, certification or professional credential disciplined, suspended or revoked?YesNo
If Yes, give a reason and explain.*field type multi line
4. Have you ever had a formal investigation or complaint filed against your license, certification or professional credential*field type radio button
4. Have you ever had a formal investigation or complaint filed against your license, certification or professional credentialYesNo
If Yes, explain.*field type multi line
Interests in High School and College*field type multi line
IN THE SPACE BELOW, DESCRIBE YOUR INTERESTS IN HIGH SCHOOL AND COLLEGE. List any clubs, sports or activities with which you were involved and what your educational goals were and are. If you did not finish High School and obtained a GED, give the circumstances involved in that decision. List any honors or awards that you received in High School or College.

Section 9: Military History

Have you ever served or ENLISTED in the United States Armed Forces or served in Texas Military Forces or other State Military Forces?*field type radio button
Have you ever served or ENLISTED in the United States Armed Forces or served in Texas Military Forces or other State Military Forces?YesNo
If Yes, Explain*field type multi line

Military Service
Provide the following information regarding your military service:
×
- Branch of Service*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Last Unit Assignment*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Are you currently enlisted?*field type radio button
  Are you currently enlisted?YesNo
- Enter your estimated discharge/exit date if you are currently enlisted
- Entry Date*field type date
- Exit Datefield type date
- Address*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Phone Numberfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Commanding Officer*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Commanding Officer Emailfield type email
- 1st Line Supervisor*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- 1st Line Supervisor Emailfield type email
- Highest Rank Held*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Rank at Dischargefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Character of Dischargefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Nature of Dischargefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Separation Codefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Re-entry Codefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
If more than one branch of service click "Add" below. To remove a branch block click the "x" to the right.Add
Answer "Yes" or "No" to the following questions. If you answer yes to any of the questions, please provide an explanation in the space provided.

Duty Stations

List all duty stations; giving dates of service. (List additional duty stations on a separate sheet if necessary).

	Installation and Unit*field type single line	City/State (Country)*field type single line	From*field type date	To*field type date
Row 1×	Installation and Unit*field type single line Input blocked. Maximum character limit of 4000 characters reached.	City/State (Country)*field type single line Input blocked. Maximum character limit of 4000 characters reached.	From*field type date	To*field type date	×

If more than one duty station click "Add" below. To remove a duty station line click the "x" to the right.Add

1. Were you discharged from the military prior to your obligation of service?*field type radio button
1. Were you discharged from the military prior to your obligation of service?YesNo
If Yes, explain.*field type multi line
2. Have you ever given the military false information (to exit the military) prior to the end of your service obligation?*field type radio button
2. Have you ever given the military false information (to exit the military) prior to the end of your service obligation?YesNo
If Yes, explain.*field type multi line
3. Were you ever A.W.O.L. or charged with desertion?*field type radio button
3. Were you ever A.W.O.L. or charged with desertion?YesNo
If Yes, give a reason and explain.*field type multi line
4. Did you receive a discharge from the military that was NOT listed as "Honorable?"*field type radio button
4. Did you receive a discharge from the military that was NOT listed as "Honorable?"YesNo
If Yes, explain.*field type multi line
5. Have you ever taken or used, sold or given away military equipment without authorization?*field type radio button
5. Have you ever taken or used, sold or given away military equipment without authorization?YesNo
If Yes, explain.*field type multi line
6. While in the military were you ever counseled or disciplined for drug or alcohol use or abuse?*field type radio button
6. While in the military were you ever counseled or disciplined for drug or alcohol use or abuse?YesNo
If Yes, why?*field type multi line
7. Has your spouse ever made or filed a complaint about you to your supervisor or commanding officer?*field type radio button
7. Has your spouse ever made or filed a complaint about you to your supervisor or commanding officer?YesNo
If Yes, why?*field type multi line
8. While in the military, did you ever commit an act which, if discovered, would have resulted in disciplinary action?*field type radio button
8. While in the military, did you ever commit an act which, if discovered, would have resulted in disciplinary action?YesNo
If Yes, explain.*field type multi line
9. Are you currently participation in one of the following?*field type radio button
9. Are you currently participation in one of the following?Military ReserveNational GuardState MilitaryN/A
Date obligation ends. (mm/dd/yyyy)?*field type date
10. While a member of the U.S. Armed Forces (active or reservist), were you ever subject of any punishment? (e.g. Court Martial, Deck Court, Captain's Mast, Summary Court, General Court, Special Court or Non-judicial Punishment (Article 15s) or company punishment?*field type radio button
10. While a member of the U.S. Armed Forces (active or reservist), were you ever subject of any punishment? (e.g. Court Martial, Deck Court, Captain's Mast, Summary Court, General Court, Special Court or Non-judicial Punishment (Article 15s) or company punishment?YesNo
Charges
×
- Charge*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Date*field type date
- Location and Unit*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Age (at the time)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Type of Punishment*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Disposition/outcome*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Explanationfield type multi line
- _________________________________________________________________________________________
If more than one charge click "Add" below. To remove a charge block click the "x" to the right.Add
In your own words and using the space below, describe your duties and accomplishments while in the military as well as any problems you might have had. Use this space to disclose any additional disciplinary actions.*field type multi line

Section 10: Financial

Answer each of the following questions. For dollar amounts, fill in the amounts to the nearest dollar.

1. What is your MONTHLY income from your primary employment? (after taxes)*field type currency
$
2. Do you have income from another source?*field type radio button
2. Do you have income from another source?YesNo
Source*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Amount*field type currency
$
3. If married, what is your spouse's net income? If not married, enter 0.00*field type currency
$
4. What Is your total Indebtedness? Include all monies you owe, whether or not you are making payments on all of the debts.*field type currency
$
5. What are your total monthly expenses, or how much do you spend each month?*field type currency
$
6. Do you have a checking account or savings account?*field type checkbox
Check all that apply. If you do not have either account type check None.
6. Do you have a checking account or savings account?CheckingSavingsNone
Checking Account Balance*field type currency
$
Savings Account Balance*field type currency
$
7. Have you ever flied for bankruptcy?*field type radio button
7. Have you ever flied for bankruptcy?YesNo
If Yes, explain.*field type multi line
8. Have you ever had any of your checks referred to a government body for insufficient funds or another non-payment? (e.g. County or District Attorney, Justice of the Peace, police, sheriff, constable, etc.)*field type radio button
8. Have you ever had any of your checks referred to a government body for insufficient funds or another non-payment? (e.g. County or District Attorney, Justice of the Peace, police, sheriff, constable, etc.)YesNo
If Yes, explain.*field type multi line
9. Have you ever written a check on a closed account?*field type radio button
9. Have you ever written a check on a closed account?YesNo
If Yes, number of times and circumstances.*field type multi line
10. Have you ever had an account referred or turned over to a collection agency?*field type radio button
10. Have you ever had an account referred or turned over to a collection agency?YesNo

Collections

If Yes, provide account holder name, highest balance, current balance, status of the account, and status of payments.

	Account holder*field type single line	Highest balance*field type currency	Current balance*field type currency	Status of account*field type single line	Status of payments*field type single line
Row 1×	Account holder*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Highest balance*field type currency $	Current balance*field type currency $	Status of account*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Status of payments*field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one account click "Add" below. To remove an account line click the "x" to the right.Add

11. Do you have any debts under another person's name?*field type radio button
11. Do you have any debts under another person's name?YesNo
If Yes, explain.*field type multi line
12. Have you been subject of foreclosure or repossession of your home, vehicle. boat, or other property?*field type radio button
12. Have you been subject of foreclosure or repossession of your home, vehicle. boat, or other property?YesNo
If Yes, explain.*field type multi line
13. Are you ln arrears of any taxes or owe money to the Internal Revenue Servlce (IRS)? or failed to file a required tax return?*field type radio button
13. Are you ln arrears of any taxes or owe money to the Internal Revenue Servlce (IRS)? or failed to file a required tax return?YesNo
If Yes, explain.*field type multi line
14. Have your wages ever been garnished?*field type radio button
14. Have your wages ever been garnished?YesNo
If Yes, explain.*field type multi line
15. Have you ever defaulted or been delinquent (failed to pay or on deferral) on a student loan?*field type radio button
15. Have you ever defaulted or been delinquent (failed to pay or on deferral) on a student loan?YesNo
If Yes, explain if it was a Federal or State guaranteed loan.*field type radio button
If Yes, explain if it was a Federal or State guaranteed loan.FederalTexasState other than Texas
What was/is the amount owed*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Current balance*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Current status of the loan*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
16. Do you currently owe the State of Texas any past due money, taxes, or payments?*field type radio button
16. Do you currently owe the State of Texas any past due money, taxes, or payments?YesNo
If Yes, explain.*field type multi line
17. Have you ever had a mechanic's lien placed against any of your property?*field type radio button
17. Have you ever had a mechanic's lien placed against any of your property?YesNo
If Yes, explain.*field type multi line
18. Have you ever borrowed money to pay a gambling debt?*field type radio button
18. Have you ever borrowed money to pay a gambling debt?YesNo
If Yes, do you have outstanding debts due to gambling?*field type radio button
If Yes, do you have outstanding debts due to gambling?YesNo
If Yes, how much debt?field type currency
$
19. Have you ever been ordered by the court to make payments or make a settlement on any debt?*field type radio button
19. Have you ever been ordered by the court to make payments or make a settlement on any debt?YesNo
If Yes, explain.*field type multi line
20. Are you under order to pay spousal (alimony) or partner support (palimony)?*field type radio button
20. Are you under order to pay spousal (alimony) or partner support (palimony)?YesNo
If Yes, disclose amount and duration.*field type multi line
21. Have you ever been court ordered to pay child support?*field type radio button
21. Have you ever been court ordered to pay child support?YesNo

Child Support

If Yes, disclose amount owed, amount past due, date of last (most recent) payment, and number of children you are paying for.

	Total amount owedfield type currency	Amount past duefield type currency	Date of last paymentfield type date	How many children?field type single line
row 1	Total amount owedfield type currency $	Amount past duefield type currency $	Date of last paymentfield type date	How many children?field type single line Input blocked. Maximum character limit of 4000 characters reached.

*** ATTENTION ***
You are required to submit a current (no more than six months old) complete credit report from one (1) of the three main credit reporting agencies (Equifax, Experian or Trans Union) with this Personal History Statement. This report may be obtained free off of the internet or directly from the credit bureau.
If you are currently ordered to make child support payments, provide documentation that indicates you payment history and current status.
A button to attach your most recent Credit Report is available on the last page.

Section 11: Financial History Breakdown

Select the type of account and provide detail for creditor name, total balance, total payment, and if the account payments are current. Enter Rent/Mortgage in the first line.

Account Type	Creditorfield type single line	Balancefield type currency	Paymentfield type currency	Current?field type drop-down
Rent/Mortgage	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Utilities/Water/Gas/Waste	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Monthly Living Expenses	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Automobile Loan (1)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Automobile Loan (2)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Auto Insurance	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Telephone Service	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Cellular Phone Service	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Cable Service	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Internet Service	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Child Care	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Child Support	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Student Loan (1)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Student Loan (2)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Credit Card (1)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Credit Card (2)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down
Credit Card (3)	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type drop-down

List others as needed

	Account Typefield type single line	Creditorfield type single line	Balancefield type currency	Paymentfield type currency	Current?field type radio button
Row 1×	Account Typefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Creditorfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Balancefield type currency $	Paymentfield type currency $	Current?field type radio button Current?YN	×

If more than one account click "Add" below. To remove an account line click the "x" to the right.Add

Section 12: Traffic and Driving History

Driver Licenses

List all driver licenses that you have ever been issued, starting with your current license.
(Include country of issue if not USA)

	State of Issuefield type single line	Driver License #field type single line	Classfield type single line	Expire Datefield type date
Row 1×	State of Issuefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Driver License #field type single line Input blocked. Maximum character limit of 4000 characters reached.	Classfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Expire Datefield type date	×

If more than one driver license click "Add" below. To remove a driver license line click the "x" to the right.Add

Vehicles Owned by You

List all vehicles that you currently own or operate.

	Makefield type single line	Modelfield type single line	Yearfield type single line	License Platefield type single line	Registered Ownerfield type single line
Row 1×	Makefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Modelfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Yearfield type single line Input blocked. Maximum character limit of 4000 characters reached.	License Platefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Registered Ownerfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one vehicle click "Add" below. To remove a vehicle line click the "x" to the right.Add

1. With whom do you have motor vehicle insurance?

Provide Company, Policy Number and Duration

	Insurance Providerfield type single line	Policy Numberfield type single line	Durationfield type single line
Row 1×	Insurance Providerfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Policy Numberfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Durationfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one policy click "Add" below. To remove a policy line click the "x" to the right.Add

2. Has your driver license ever been suspended or revoked?*field type radio button
2. Has your driver license ever been suspended or revoked?YesNo
If Yes, explain number of times and reasons.*field type multi line
3. Have you ever been arrested or charged with any traffic related offenses involving drugs or alcohol?*field type radio button
3. Have you ever been arrested or charged with any traffic related offenses involving drugs or alcohol?YesNo
If Yes, when and what?*field type multi line
4. Have you ever driven a vehicle without insurance as required by law?*field type radio button
4. Have you ever driven a vehicle without insurance as required by law?YesNo
If Yes, explain.*field type multi line
5. Have you ever had a warrant issued for unpaid traffic tickets?*field type radio button
5. Have you ever had a warrant issued for unpaid traffic tickets?YesNo
If Yes, explain.*field type multi line
6. Do you currently have any unpaid traffic tickets?*field type radio button
6. Do you currently have any unpaid traffic tickets?YesNo
If Yes, explain.*field type multi line
7. Have you ever or are you currently under surcharge (Drivers Responsibility Program) fine with the State of Texas?*field type radio button
7. Have you ever or are you currently under surcharge (Drivers Responsibility Program) fine with the State of Texas?YesNo
If Yes, when and balance due?*field type multi line
8. Have you ever been charged or accused of hit and run, failure to stop and render aid, or fleeing the scene of an accident?*field type radio button
8. Have you ever been charged or accused of hit and run, failure to stop and render aid, or fleeing the scene of an accident?YesNo
If Yes, explain when and where?*field type multi line
9. Have you ever been involved in a traffic accident, as a driver (even solo driving accidents)?*field type radio button
9. Have you ever been involved in a traffic accident, as a driver (even solo driving accidents)?YesNo
Traffic Accidents
List all traffic accidents in which you have been involved, as a driver (even solo driver accidents), and give the information requested. If you do not recall the exact date of accident, enter a date closest to date of accident.
×
- Date of Accident*field type date
- Location*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Police Investigation?*field type radio button
  Police Investigation?YesNo
- If Police Investigation, by Whom?*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Cause of Accident (e.g. ran a red light, rain, careless, etc)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Who was at fault?*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
If more than one traffic accident click "Add" below. To remove a traffic accident block click the "x" to the right.Add
10. Have you ever been issued a traffic citation, including those that do and do not appear on your driving record (excluding parking tickets)?*field type radio button
10. Have you ever been issued a traffic citation, including those that do and do not appear on your driving record (excluding parking tickets)?YesNo
Traffic Citations
List, to the best of your memory, all traffic citations you have ever received, (excluding parking citations). Include those that do and do not appear on your driving record and give a disposition (guilty, not guilty, nolo contendere, no contest, or dismissed) of each. If dismissed, list reason for dismissal (probation, plea agreement, deferred adjudication, etc.) of each. Where multiple violations were issued on a single traffic stop, list each as an individual violation. Include citations issued as a result of a traffic accident. List red light camera violations where you were the driver. List other court requirements (community service, driver safety classes, probation, alcohol testing, etc.).
×
- Month/Year*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Charge*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Issuing Agency/Location (City/State)*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Disposition/Terms*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Fine or Fee Paid*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Other Court Requirements*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- _________________________________________________________________________________________
If more than one traffic citation click "Add" below. To remove a traffic citation block click the "x" to the right.Add

Section 13: Criminal History

Have you have ever been stopped, detained, searched, arrested, charged, issued a misdemeanor citation, given a sobriety test or questioned by the police for any reason? (Including violations of Uniform Code of Military Justice and pending charges). Excluding Traffic.*field type radio button
Have you have ever been stopped, detained, searched, arrested, charged, issued a misdemeanor citation, given a sobriety test or questioned by the police for any reason? (Including violations of Uniform Code of Military Justice and pending charges). Excluding Traffic.YesNo
Disclosure of Citations, Arrests, and Convictions:
List all occasions you have been stopped, detained, searched, arrested, charged, issued a misdemeanor citation, given a sobriety test or questioned by the police for any reason. (Including violations of Uniform Code of Military Justice and pending charges). Exclude Traffic
×
- Agency*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Date*field type date
- Location*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Arrested?*field type radio button
  Arrested?YesNo
- Citation?*field type radio button
  Citation?YesNo
- Charge*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Plea*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Fine/Fee*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Disposition/Punishment*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Brief Explanation*field type multi line
If more than one citation, arrest or conviction click "Add" below. To remove a citation, arrest or conviction block click the "x" to the right.Add

Section 14: Criminal History and Illegal Behaviors

1. Have you ever been summoned into any court of law? (Other than jury duty).*field type radio button
1. Have you ever been summoned into any court of law? (Other than jury duty).YesNo
If Yes, explain*field type multi line
2. Have you ever lied under oath, been accused of perjury, held in contempt, or been sanctioned in any court of law or administrative hearing?*field type radio button
2. Have you ever lied under oath, been accused of perjury, held in contempt, or been sanctioned in any court of law or administrative hearing?YesNo
If Yes, explain*field type multi line
3. Have you ever been a party in a civil lawsuit, or ever sued anyone (plaintiff) or been sued by someone (respondent/defendant)? (e.g. small claims actions, dissolutions, child custody, paternity, etc.)?*field type radio button
3. Have you ever been a party in a civil lawsuit, or ever sued anyone (plaintiff) or been sued by someone (respondent/defendant)? (e.g. small claims actions, dissolutions, child custody, paternity, etc.)?YesNo
If Yes, explain*field type multi line
4. Have you ever had a warrant issued for your arrest?*field type radio button
4. Have you ever had a warrant issued for your arrest?YesNo
If Yes, explain*field type multi line
5. Have you ever been placed on probation or parole? (Includes: Unadjudicated, Informal, Formal, Supervised or Unsupervised).*field type radio button
5. Have you ever been placed on probation or parole? (Includes: Unadjudicated, Informal, Formal, Supervised or Unsupervised).YesNo
If Yes, explain*field type multi line
6. Have you ever been involved in any incident, including a disturbance, where the police were summoned? (Whether or not you were present when they arrived)?*field type radio button
6. Have you ever been involved in any incident, including a disturbance, where the police were summoned? (Whether or not you were present when they arrived)?YesNo
If Yes, explain*field type multi line
7. Have the police ever raided, served or executed a warrant on your home, residence, business, person or property?field type radio button
7. Have the police ever raided, served or executed a warrant on your home, residence, business, person or property?YesNo
If Yes, explain*field type multi line
8. Since the age of 17, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act?field type radio button
8. Since the age of 17, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act?YesNo
If Yes, explain*field type multi line
9. Have you ever used force or violence against another person with whom you were dating, in a romantic or intimate relationship, married to or with whom you resided in your same household or domicile?field type radio button
9. Have you ever used force or violence against another person with whom you were dating, in a romantic or intimate relationship, married to or with whom you resided in your same household or domicile?YesNo
If Yes, explain*field type multi line
10. Where you ever required to appear before a juvenile court for an act which would have been a crime if committed as an adult?*field type radio button
10. Where you ever required to appear before a juvenile court for an act which would have been a crime if committed as an adult?YesNo
If Yes, explain*field type multi line
11. Have you ever been named in a Peace Bond, Restraining Order, Protective Order or similar order of the court?*field type radio button
11. Have you ever been named in a Peace Bond, Restraining Order, Protective Order or similar order of the court?YesNo
If Yes, explain*field type multi line
12. Have you ever, been accused of, investigated, committed, charged with or convicted of domestic or family violence or abuse?*field type radio button
12. Have you ever, been accused of, investigated, committed, charged with or convicted of domestic or family violence or abuse?YesNo
If Yes, explain*field type multi line
13. Have you ever committed or been investigated for child, elderly or spousal abuse or neglect?*field type radio button
13. Have you ever committed or been investigated for child, elderly or spousal abuse or neglect?YesNo
If Yes, explain*field type multi line
14. Are you a fugitive from justice, under indictment, currently charged with or a suspect in any crime or have a warrant?*field type radio button
14. Are you a fugitive from justice, under indictment, currently charged with or a suspect in any crime or have a warrant?YesNo
If Yes, explain*field type multi line
15. Since you were 17 years old, have you ever stolen any cash money? Or other property or item of value?*field type radio button
15. Since you were 17 years old, have you ever stolen any cash money? Or other property or item of value?YesNo
If Yes, explain*field type multi line
16. Have you ever knowingly received or accepted stolen property from another person?*field type radio button
16. Have you ever knowingly received or accepted stolen property from another person?YesNo
If Yes, explain*field type multi line
17. Have you ever smuggled drugs, money, weapons or other thing of value, into or out of this state, or into or out of this country?*field type radio button
17. Have you ever smuggled drugs, money, weapons or other thing of value, into or out of this state, or into or out of this country?YesNo
If Yes, explain*field type multi line
18. Have you ever been involved, in any way, with the trafficking of people?*field type radio button
18. Have you ever been involved, in any way, with the trafficking of people?YesNo
If Yes, explain*field type multi line
19. Have you ever worked as a prostitute, escort, madam or pimp, or accepted money, drugs or other thing of value in return for sex (or providing sex)?*field type radio button
19. Have you ever worked as a prostitute, escort, madam or pimp, or accepted money, drugs or other thing of value in return for sex (or providing sex)?YesNo
If Yes, explain*field type multi line
20. Have you ever engaged in prostitution or solicitation of prostitution (sexual tourism)? Including patronizing illegal massage parlor(s).*field type radio button
20. Have you ever engaged in prostitution or solicitation of prostitution (sexual tourism)? Including patronizing illegal massage parlor(s).YesNo
If Yes, explain*field type multi line
21. Have you ever viewed, possessed, produced or distributed child pornography or engaged in sexual solicitation or assault of a child?*field type radio button
21. Have you ever viewed, possessed, produced or distributed child pornography or engaged in sexual solicitation or assault of a child?YesNo
If Yes, explain*field type multi line
22. Have you ever engaged in or convicted of computer crimes or identity theft?*field type radio button
22. Have you ever engaged in or convicted of computer crimes or identity theft?YesNo
If Yes, explain*field type multi line
23. Have you ever committed, been accused, or convicted of Public Lewdness, Indecent Exposure, Obscenity or a sex crime?*field type radio button
23. Have you ever committed, been accused, or convicted of Public Lewdness, Indecent Exposure, Obscenity or a sex crime?YesNo
If Yes, explain*field type multi line
24. Have you ever committed, been accused of or convicted of fraud or embezzlement?*field type radio button
24. Have you ever committed, been accused of or convicted of fraud or embezzlement?YesNo
If Yes, explain*field type multi line
25. Have you ever committed, been accused of or convicted of malicious destruction of property or criminal mischief?*field type radio button
25. Have you ever committed, been accused of or convicted of malicious destruction of property or criminal mischief?YesNo
If Yes, explain*field type multi line
26. Have you ever burglarized a commercial business, dwelling, house, vehicle, garage, shed or vacant/ abandoned property?*field type radio button
26. Have you ever burglarized a commercial business, dwelling, house, vehicle, garage, shed or vacant/ abandoned property?YesNo
If Yes, explain*field type multi line
27. Have you ever committed, been accused of or convicted of the crime of arson, attempted arson; or juvenile fire-starting? or intentionally ignited or attempted to light a fire for excitement or sexual gratification?*field type radio button
27. Have you ever committed, been accused of or convicted of the crime of arson, attempted arson; or juvenile fire-starting? or intentionally ignited or attempted to light a fire for excitement or sexual gratification?YesNo
If Yes, explain*field type multi line
28. Have you ever been a member of a criminal street gang, paramilitary organization, hate crime or violent group(s), or have tattoo(s), brands or other marking signifying membership or affiliation with such a group or groups?*field type radio button
28. Have you ever been a member of a criminal street gang, paramilitary organization, hate crime or violent group(s), or have tattoo(s), brands or other marking signifying membership or affiliation with such a group or groups?YesNo
If Yes, explain*field type multi line
29. Have you ever committed, planned, organized or participated in a hate crime, riot or civil disturbance or protest?*field type radio button
29. Have you ever committed, planned, organized or participated in a hate crime, riot or civil disturbance or protest?YesNo
If Yes, explain*field type multi line
30. Have you ever committed any act that was or would have been a felony, (even if not caught, charged or indicted)? Including while in the military or committed in another state, on foreign soil or at seas.*field type radio button
30. Have you ever committed any act that was or would have been a felony, (even if not caught, charged or indicted)? Including while in the military or committed in another state, on foreign soil or at seas.YesNo
If Yes, explain*field type multi line
31. Have you ever settled any civil suit in which you, your insurance company, or anyone else on your behalf was required to make payment(s) to any other party?*field type radio button
31. Have you ever settled any civil suit in which you, your insurance company, or anyone else on your behalf was required to make payment(s) to any other party?YesNo
If Yes, explain*field type multi line
32. Have you ever fraudulently received welfare, unemployment compensation, worker's compensation or other state or federal assistance?*field type radio button
32. Have you ever fraudulently received welfare, unemployment compensation, worker's compensation or other state or federal assistance?YesNo
If Yes, explain*field type multi line
33. Have you ever filed a false insurance claim or worker's compensation claim?*field type radio button
33. Have you ever filed a false insurance claim or worker's compensation claim?YesNo
If Yes, explain*field type multi line
34. Have you ever been required to repay any welfare payments, unemployment compensation or other state or federal assistance?*field type radio button
34. Have you ever been required to repay any welfare payments, unemployment compensation or other state or federal assistance?YesNo
If Yes, explain*field type multi line
35. Have you ever been accused or convicted of animal endangerment, animal cruelty or abuse or neglect of an animal?*field type radio button
35. Have you ever been accused or convicted of animal endangerment, animal cruelty or abuse or neglect of an animal?YesNo
If Yes, explain*field type multi line
36. Have you ever committed, been accused of filing or making a false report to police; or altering or forging a government document?*field type radio button
36. Have you ever committed, been accused of filing or making a false report to police; or altering or forging a government document?YesNo
If Yes, explain*field type multi line
37. Have you ever committed, been accused of or convicted of stalking, harassing, spying or peeping on anyone with or without their knowledge?*field type radio button
37. Have you ever committed, been accused of or convicted of stalking, harassing, spying or peeping on anyone with or without their knowledge?YesNo
If Yes, explain*field type multi line
38. Have you ever committed, been accused of or convicted of unlawfully carrying a weapon (with or without a permit), had a weapon's charge or brandished a weapon?*field type radio button
38. Have you ever committed, been accused of or convicted of unlawfully carrying a weapon (with or without a permit), had a weapon's charge or brandished a weapon?YesNo
If Yes, explain*field type multi line
39. Have you ever impersonated, or attempted to impersonate a police (peace) officer (or another public servant)?*field type radio button
39. Have you ever impersonated, or attempted to impersonate a police (peace) officer (or another public servant)?YesNo
If Yes, explain*field type multi line
40. Have you ever committed, been accused of or convicted of, sexual harassment, violence in the workplace, discrimination, blackmail or extortion?*field type radio button
40. Have you ever committed, been accused of or convicted of, sexual harassment, violence in the workplace, discrimination, blackmail or extortion?YesNo
If Yes, explain*field type multi line
41. Has any member of your immediate family ever been arrested or convicted of a criminal offense?*field type radio button
41. Has any member of your immediate family ever been arrested or convicted of a criminal offense?YesNo

	Namefield type single line	Relationshipfield type single line	Offense and level of offensefield type single line	Plea/Disposition (penalty)field type single line
Row 1×	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationshipfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Offense and level of offensefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Plea/Disposition (penalty)field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one click "Add" below. To remove a line click the "x" to the right.Add

Section 15: Illegal Drug Usage

Check "Yes" or "No" to indicate whether or not you have ever personally used, possessed or sold any of the drugs listed below. If "Yes," report the number of times, the approximate last date and the form of the substance (e.g. powder, leaf, liquid pill, etc.). Do not list those occassions you came into contact with any illegal drugs in the performance of your professional duties. Include use of prescriptions medications used for the purposes of intoxication or used when prescribed to someone other than you.

Type/Name of Drug	Illegal Use*field type radio button	# Times*field type number	Approx. Last Date*field type single line	Form(s) of Substance & reason for use*field type single line
Marijuana	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Synthetic	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Hashish/Hash Oil	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Amphetamine (Speed)	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Methamphetamine	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Ecstasy/MDMA/Molly	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Bath Salts (Synthetic Cathinone)	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
GHB	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Rohypnol/Flunitrazepam	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Cocaine/Crack	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
LSD (Acid)	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
PCP/Angel Dust	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Ketamine	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Peyote/Mescaline	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Mushrooms/Psilocybin	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Tranquilizers	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Barbiturates	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Quaaludes	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Heroin/ Opium	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Anabolic Steroids	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Pain Medication (prescription)	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.
Inhalants (glue, paint, etc.)	Illegal Use*field type radio button Illegal UseYN	# Times*field type number	Approx. Last Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Form(s) of Substance & reason for use*field type single line Input blocked. Maximum character limit of 4000 characters reached.

Any other illegal drug*field type radio button
Any other illegal drugYN
If "Yes" to Any other illegal drug, give details, including drug(s) used and circumstances:*field type multi line

Section 17: Prior Fire, EMS or Public Service Experience

1. Have you ever made and application for employment with any Public Safety agency?*field type radio button
1. Have you ever made and application for employment with any Public Safety agency?YesNo

If Yes, list those agencies below, (Police, Fire, Ems, Boarder Patrol, Lifeguard, Security or Corrections, etc.).

	Agency*field type single line	Date of Application*field type single line	Status of Application*field type single line	Stage of Eliminationfield type single line	Cause of Eliminationfield type single line
Row 1×	Agency*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Date of Application*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Status of Application*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Stage of Eliminationfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Cause of Eliminationfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one Agency click "Add" below. To remove an Agency line click the "x" to the right.Add

2. Have you ever been employed (paid) by a Fire, EMS, Law Enforcement or other Public Safety organization?*field type radio button
2. Have you ever been employed (paid) by a Fire, EMS, Law Enforcement or other Public Safety organization?YesNo

If Yes, list those agencies.

	Agency*field type single line	Position*field type single line	Reason for Leaving*field type single line	Statusfield type single line
Row 1×	Agency*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Position*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Reason for Leaving*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Statusfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one Agency click "Add" below. To remove an Agency line click the "x" to the right.Add

3. Have you ever volunteered (even if received a stipend) with a Fire, EMS, Law Enforcement or other Public Safety organization?*field type radio button
3. Have you ever volunteered (even if received a stipend) with a Fire, EMS, Law Enforcement or other Public Safety organization?YesNo

If Yes, list those agencies.

	Agency*field type single line	Position*field type single line	Reason for Leaving*field type single line	Statusfield type single line
Row 1×	Agency*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Position*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Reason for Leaving*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Statusfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one Agency click "Add" below. To remove an Agency line click the "x" to the right.Add

4. List all Corpus Christi Firefighters or Fire Department employee(s), (or City of Corpus Christi employee(s)) with whom you are related or closely acquainted.field type radio button
4. List all Corpus Christi Firefighters or Fire Department employee(s), (or City of Corpus Christi employee(s)) with whom you are related or closely acquainted.

	Employee Namefield type single line	Dept/Divisionfield type single line	Relationshipfield type single line	Duration of Acquaintancefield type single line
Row 1×	Employee Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Dept/Divisionfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationshipfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Duration of Acquaintancefield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

If more than one click "Add" below. To remove a line click the "x" to the right.Add

5. Do you have any religious, (or other beliefs), which would prevent you from fully performing the duties of a firefighter or paramedic, including working on weekends, holidays, evenings or night shifts? Being exposed to illness, injuries, blood or dead or dying people.?*field type radio button
5. Do you have any religious, (or other beliefs), which would prevent you from fully performing the duties of a firefighter or paramedic, including working on weekends, holidays, evenings or night shifts? Being exposed to illness, injuries, blood or dead or dying people.?YesNo
If Yes, explain.*field type multi line
6. Have you ever been refused a permit to carry a concealed weapon?*field type radio button
6. Have you ever been refused a permit to carry a concealed weapon?YesNo
If Yes, explain.*field type multi line
7. Have you ever had a mental break, attempted to injury yourself or attempted to commit suicide?*field type radio button
7. Have you ever had a mental break, attempted to injury yourself or attempted to commit suicide?YesNo
If Yes, explain.*field type multi line
8. Do you believe you are physically and mentally capable of preforming the duties of a firefighter and paramedic?*field type radio button
8. Do you believe you are physically and mentally capable of preforming the duties of a firefighter and paramedic?YesNo
If No, explain.*field type multi line
9. Are there any incidents in your life or details not mentioned herein which may influence this department’s evaluation of your suitability for employment as a firefighter?*field type radio button
9. Are there any incidents in your life or details not mentioned herein which may influence this department’s evaluation of your suitability for employment as a firefighter?YesNo
If Yes, explain.*field type multi line
10. In your own words, describe what qualities and characteristics you think are important for a Firefighter or Paramedic to have and explain:*field type multi line

*** It is recommended to provide a PDF or JPG file format during the document upload process. It is your responsibility to provide a clear image for all applicable documentation. Images that contain a glare, overcast lighting, or are dark, blurry, or otherwise unreadable may result in an incomplete application***.

Section 18: Document Attach and Attestation

Education, Training, and Certificates

High School Diploma or GED*field type file upload
Drop files here
You have reached the maximum file limit: .
file format must be pdf, jpg
Have you requested a copy of your High School Diploma/GED but not received it?field type checkbox
Have you requested a copy of your High School Diploma/GED but not received it?Yes
High School Transcript(s)*field type file upload
Drop files here
You have reached the maximum file limit: .
file format must be pdf, jpg
Have you requested a copy of your High School Transcript but not received it?field type checkbox
Have you requested a copy of your High School Transcript but not received it?Yes
Official Copy of College Transcript(s)*field type file upload
Drop files here
You have reached the maximum file limit: .
file format must be pdf, jpg, tif, tiff, jpg
Have you requested a copy of your College Transcript but not received it?field type checkbox
Have you requested a copy of your College Transcript but not received it?Yes
College Diploma(s)*field type file upload
Drop files here
You have reached the maximum file limit: .
file format must be pdf, jpg
Have you requested a copy of your College Diploma but not received it?field type checkbox
Have you requested a copy of your College Diploma but not received it?Yes
Applicable Training Certificates or Licensesfield type file upload
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file format must be pdf, jpg

Financial

Complete Credit Report (Equifax, Experian or TransUnion)*field type file upload
Drop files here
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file format must be pdf, jpg
Documentation of Up-to-Date Child Support Payments*field type file upload
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file format must be pdf, jpg

Motor Vehicle and Drivers License

Proof of Motor Vehicle Liability Insurance*field type file upload
Drop files here
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file format must be pdf, jpg
Current Driver License*field type file upload
Drop files here
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file format must be pdf, jpg
Out of State Driver License (if applicable)field type file upload
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file format must be pdf, jpg

Marriage and Divorce

Marriage License(s) * (required if you have EVER been married)field type file upload
Attach Marriage Licenses from ALL Marriages
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file format must be pdf, jpg
Final Divorce Decree(s) * (required if you have EVER been divorced)field type file upload
Attach Divorce Decrees from ALL Divorces
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file format must be pdf, jpg

Military

Selective Service Registration (males only)field type file upload
To obtain a copy of your Selective Service Registration visit: https://www.sss.gov/verify/
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file format must be pdf, jpg
DD-214, NG-22 or other (if military service)*field type file upload
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file format must be pdf, jpg

Authorization and Release

Authorization to Release Information (***Signed & Notarized)
Download Authorization To Release Information prior to completing this application. Click Here
Authorization to Release Information*field type file upload
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file format must be pdf, jpg
Authorization to Release Information-Military (*** Signed & Notarized)
Download Authorization to Release Information-Military prior to completing this application. Click Here
Authorization to Release Information (Military Records)*field type file upload
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ATTESTATION:
I HEREBY CERTIFY THAT THERE ARE NO WILLFUL MISREPRESENTATIONS, OMISSIONS, OR FALISFICATIONS IN THE FOREGOING STATEMENTS AND ANSWERS TO QUESTIONS. I AM FULLY AWARE THAT ANY SUCH WILLFUL MISREPRESENATIONS, OMISSIONS, OR FALISIFICATIONS MAY BE GROUNDS FOR IMMEDIATE REJECTION OF THIS APPLICATION OR TERMINATION OF EMPLOYMENT.
Signature of Applicant*field type signature
Printed Name of Applicant*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Datefield type date
Date will be captured on form submission

Corpus Christi Fire DepartmentPersonal History Statement

Personal History Statement Instructions

Required Documentation

Additional Instructions

Section 1: Personal Information

Other names you have used or been known by (including maiden names, nicknames, birth names, and legally changed names)

Email address (List all other email addresses, if any)

Place of Birth (City, County, State, Country)

Physical Description

List and describe all scars, tattoos and other distinguishing marks

Court Orders

Section 1 A: Marital Status

Section 1 C: Immediate Relatives

Section 2: Personal References

Personal References

Section 3: Residences

Residence(s) (current residence first)

States

Section 4: Behavior as a Tenant/Occupant

Section 5: Employment

Employer(s) (most recent first)

Section 6: Employment Behavior

Section 7: Education History

High School(s) or Home Schools

Professional Licenses, Certifications or Credentials

Special License or Advanced Training Certificates

Languages

Section 8: Education Behavior

Section 9: Military History

Section 10: Financial

Section 11: Financial History Breakdown

List others as needed

Section 12: Traffic and Driving History

Driver Licenses

Vehicles Owned by You

1. With whom do you have motor vehicle insurance?

Section 13: Criminal History

Section 14: Criminal History and Illegal Behaviors

Section 15: Illegal Drug Usage

Section 16: Alcohol and Illegal Drug Behavior

Section 17: Prior Fire, EMS or Public Service Experience

Section 18: Document Attach and Attestation

Education, Training, and Certificates

Financial

Motor Vehicle and Drivers License

Marriage and Divorce

Military

Authorization and Release

Corpus Christi Fire Department
Personal History Statement