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Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 1 of 10 Revised 3/2022 PARK COUNTY EMERGENCY COMMUNICATIONS CENTER PERSONAL HISTORY STATEMENT DATE: GENERAL INSTRUCTIONS: Hand print or type an answer to every question. If the question does not apply to you, so state with N/A. If the space available is insufficient, use a separate sheet. DO NOT MISSTATE OR OMIT material facts, since the statements made herein are subject to verification to determine your eligibility for employment. FALSIFICATION OR OMISSION OF ANY MATERIAL INFORMATION IN THIS DOCUMENT MAY RESULT IN THE PERMANENT REJECTION OF YOUR APPLICATION FOR EMPLOYMENT. APPLICANT: NAME: Last First Middle OTHER NAMES: (Nicknames, alias, maiden, etc.) ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUS PHONE: CELL PHONE: PAGER: EMAIL: DL#: STATE: HT: WT: COLOR OF EYES: COLOR OF HAIR: PLACE OF BIRTH: City County State ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES? YES NO SCARS, MARKS, TATTOOS: WORK EXPERIENCE: BEGINNING WITH YOUR CURRENT OR MOST RECENT JOB, LIST ALL OF THE JOBS YOU HAVE HAD IN THE PAST TEN (10) YEARS. INCLUDE ALL PART TIME, TEMPORARY OR SEASONAL POSITIONS. ATTACH ADDITIONAL PAGES, IF NECESSARY. A JOB IS ANY POSITION YOU ACCEPTED REGARDLESS OF HOW LONG YOU ACTUALLY WORKED. CIRCLE APPROPRIATE JOB DESCRIPTION: FULL TIME PART TIME TEMPORARY SEASONAL FROM: TO: NAME OF EMPLOYER/COMPANY: ADDRESS: CITY: STATE: ZIP: PHONE: HIGHEST SALARY: POSITION HELD: NAME OF LAST SUPERVISOR: LIST TWO COWORKERS: DESCRIBE DUTIES AND RESPONSIBILITIES: DID YOU RECEIVE JOB PERFORMANCE EVALUATIONS WHILE WITH THIS COMPANY? YES NO ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 2 of 10 Revised 3/2022 ARE YOU ELIGIBLE FOR REHIRE? YES NO LIST REASONS FOR LEAVING THIS POSITION: WORK EXPERIENCE: CIRCLE APPROPRIATE JOB DESCRIPTION: FULL TIME PART TIME TEMPORARY SEASONAL FROM: TO: NAME OF EMPLOYER/COMPANY: ADDRESS: CITY: STATE: ZIP: PHONE: HIGHEST SALARY: POSITION HELD: NAME OF LAST SUPERVISOR: LIST TWO COWORKERS: DESCRIBE DUTIES AND RESPONSIBILITIES: DID YOU RECEIVE JOB PERFORMANCE EVALUATIONS WHILE WITH THIS COMPANY? YES NO ARE YOU ELIGIBLE FOR REHIRE? YES NO LIST REASONS FOR LEAVING THIS POSITION: WORK EXPERIENCE: CIRCLE APPROPRIATE JOB DESCRIPTION: FULL TIME PART TIME TEMPORARY SEASONAL FROM: TO: NAME OF EMPLOYER/COMPANY: ADDRESS: CITY: STATE: ZIP: PHONE: HIGHEST SALARY: POSITION HELD: NAME OF LAST SUPERVISOR: LIST TWO COWORKERS: DESCRIBE DUTIES AND RESPONSIBILITIES: ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 3 of 10 Revised 3/2022 DID YOU RECEIVE JOB PERFORMANCE EVALUATIONS WHILE WITH THIS COMPANY? YES NO ARE YOU ELIGIBLE FOR REHIRE? YES NO LIST REASONS FOR LEAVING THIS POSITION: WORK EXPERIENCE: CIRCLE APPROPRIATE JOB DESCRIPTION: FULL TIME PART TIME TEMPORARY SEASONAL FROM: TO: NAME OF EMPLOYER/COMPANY: ADDRESS: CITY: STATE: ZIP: PHONE: HIGHEST SALARY: POSITION HELD: NAME OF LAST SUPERVISOR: LIST TWO COWORKERS: DESCRIBE DUTIES AND RESPONSIBILITIES: DID YOU RECEIVE JOB PERFORMANCE EVALUATIONS WHILE WITH THIS COMPANY? YES NO ARE YOU ELIGIBLE FOR REHIRE? YES NO LIST REASONS FOR LEAVING THIS POSITION: PERIODS OF UNEMPLOYMENT: RECORD ANY PERIOD OF UNEMPLOYMENT YOU HAVE HAD IN THE PAST FIVE YEARS (a period of unemployment is any time you did not have a job). FROM: (MO/YR) TO: (MO/YR) TOTAL TIME UNEMPLOYED REASON FOR UNEMPLOYMENT ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 4 of 10 Revised 3/2022 EDUCATIONAL HISTORY: LIST ALL HIGH SCHOOLS, COLLEGES, TECHNICAL OR TRADE SCHOOLS YOU HAVE EVER ATTENDED REGARDLESS OF WHETHER OR NOT YOU GRADUATED AND/OR COMPLETED THE PRESCRIBED COURSE OF STUDY. IF YOU LIST COLLEGES/UNIVERSITIES AND YOU DID NOT GRADUATE, INDICATE THE CORRECT NUMBER OF CREDIT HOURS YOU RECEIVED FROM EACH. IF YOU ATTENDED A TECHNICAL OR TRADE SCHOOL, INDICATE YOUR COURSE OF STUDY AND WHETHER YOU WERE AWARDED A DIPLOMA OR CERTIFICATE. NAME AND TYPE OF SCHOOL LOCATION (CITY & STATE) DATES ATTENDED FROM DATES ATTENDED TO DEGREE AND/OR CREDIT HOURS HAVE YOU EVER BEEN EXPELLED FROM ANY SCHOOL YOU ATTENDED? YES NO IF YES, GIVE SCHOOL, DATE(S), AND REASON: HAVE YOU EVER BEEN PLACED ON ACADEMIC PROBATION? YES NO IF YES, GIVE SCHOOL, DATE AND REASON: IF YOU ARE FLUENT IN A FOREIGN LANGUAGE, INDICATE EACH LANGUAGE AND YOUR DEGREE OF FLUENCY (EXCELLENT, GOOD, FAIR) IN EACH AREA: LANGUAGE READ SPEAK/UNDERSTAND WRITE LICENSING: LIST ANY SPECIAL LICENSES YOU HOLD (RADIO, PILOT, TELECOMMUNICATIONS OPERATOR, JAILER, ETC.) SHOW LICENSING AUTHORITY, LICENSE NUMBER, EXPIRATION if applicable: ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 5 of 10 Revised 3/2022 MILITARY SERVICE: HAVE YOU EVER BEEN A MEMBER OF ANY BRANCH OF THE UNITED STATES ARMED FORCES? YES NO BRANCH: SERVICE DATE OF INDUCTION: DATE DISCHARGED: LAST UNIT ASSIGNED: HIGHEST RANK ATTAINED: AWARDS RECEIVED: ARE YOU CURRENTLY A MEMBER OF A U.S. RESERVE, NATIONAL, OR STATE GUARD ORGANIZATION? YES NO WHAT ORGANIZATION? RANK: CRIMINAL CONVICTIONS: HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A TRAFFIC INFRACTION? YES NO IF YES, EXPLAIN EACH INCIDENT (LIST JUVENILE AS WELL AS ADULT OCCURENCES). USE ADDITIONAL SHEETS IF NECESSARY. FOR EACH INCIDENT, THE COURT DISPOSITION AND OFFENSE REPORT ARE REQUIRED. CHARGE DATE DISPOSITION DETAILED SYNOPSIS: CHARGE DATE DISPOSITION DETAILED SYNOPSIS: CHARGE DATE DISPOSITION DETAILED SYNOPSIS: LITIGATION: HAVE YOU EVER BEEN INVOLVED IN ANY KIND OF LAW SUIT (EVEN AS A WITNESS)? YES NO WERE YOU SUED? YES NO HAVE YOU EVER SUED ANYONE? YES NO IF YES, EXPLAIN EACH INCIDENT. USE ADDITIONAL SHEETS IF NECESSARY. ATTACH COPIES OF ALL DOCUMENTS. ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 6 of 10 Revised 3/2022 SUIT DATE DISPOSITION DETAILED SYNOPSIS: DRIVING RECORD: HAVE YOU EVER DRIVEN A MOTOR VEHICLE, SINCE YOUR 17TH BIRTHDAY WITHOUT A VALID DRIVER’S LICENSE? YES NO HAVE YOU EVER DRIVEN A MOTOR VEHICLE, WITHIN THE PAST THREE YEARS WITHOUT PROPER INSURANCE? YES NO HAVE YOU EVER HAD YOUR DRIVER’S LICENSE SUSPENDED OR PLACED ON PROBATION? YES NO IF YES, EXPLAIN (ATTACH ADDITIONAL SHEETS IF NECESSARY). SHOW DATE, TYPE OF SUSPENSION, AND DATE SUSPENSION WAS LIFTED: HAVE YOU EVER KNOWINGLY DRIVEN A MOTOR VEHICLE AFTER YOUR DRIVER’S LICENSE WAS SUSPENDED OR REVOKED? YES NO HAVE YOU EVER HAD A VALID DRIVER’S LICENSE IN ANOTHER STATE? YES NO IF YES, LIST DL NUMBER AND STATE: HAVE YOU EVER BEEN DENIED A DRIVER’S LICENSE FOR ANY REASON? YES NO IF YES, EXPLAIN: HAVE YOU EVER BEEN INVOLVED IN AN ACCIDENT AND LEFT THE SCENE WITHOUT IDENTIFYING YOURSELF? YES NO HAVE YOU EVER STRUCK AN UNATTENDED VEHICLE AND THEN LEFT WITHOUT LEAVING PROPER IDENTIFICATION? YES NO HAVE YOU EVER BEEN INVOLVED IN AN ACCIDENT WHEN YOU WERE DRIVING AFTER YOU HAD BEEN DRINKING ANY TYPE OF ALCOHOLIC BEVERAGE? YES NO IF YES, EXPLAIN: ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 7 of 10 Revised 3/2022 LIST, ALL MOVING AND NON-MOVING CITATIONS YOU HAVE RECEIVED IN THE PAST FIVE YEARS: DATE VIOLATION AGENCY DISPOSITION LIST ALL ACCIDENTS IN WHICH YOU WERE INVOLVED AS A DRIVER IN THE PAST FIVE YEARS: DATE LOCATION BRIEF DESCRIPTION WITH WHAT COMPANY DO YOU CARRY AUTOMOBILE INSURANCE? NAME: ADDRESS: CITY: STATE: ZIP: AGENT: PHONE: POLICY EXP. DATE: RESIDENCES: LIST ALL RESIDENCES WHERE YOU HAVE LIVED FOR THE PAST FIVE YEARS. BEGIN WITH YOUR CURRENT RESIDENCE. LIST BY MONTH AND YEAR. INCLUDE APARTMENT COMPLEX NAMES AND OFFICE PHONE NUMBERS. ATTACH ADDITIONAL PAGES IF NECESSARY. FROM/TO: OFFICE PHONE: ADDRESS: CITY: STATE: ZIP: APARTMENT COMPLEX NAME: ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 8 of 10 Revised 3/2022 FROM/TO: OFFICE PHONE: ADDRESS: CITY: STATE: ZIP: APARTMENT COMPLEX NAME: FROM/TO: OFFICE PHONE: ADDRESS: CITY: STATE: ZIP: APARTMENT COMPLEX NAME: FROM/TO: OFFICE PHONE: ADDRESS: CITY: STATE: ZIP: APARTMENT COMPLEX NAME: UNDETECTED CRIMES: HAVE YOU EVER SOLD OR FURNISHED DRUGS OR NARCOTICS TO ANYONE? YES NO IF YES, GIVE DETAILS: HAVE YOU EVER TAKEN PRESCRIPTION DRUGS NOT PRESCRIBED TO YOU BY YOUR PHYSICIAN? YES NO IF YES, GIVE DETAILS: HAVE YOU EVERY TAKEN/USED ANY ILLEGAL NARCOTICS? YES NO IF YES, GIVE DETAILS: HAS ANOTHER INDIVIDUAL EVER USED DRUGS IN YOUR PRESENCE? YES NO IF YES, GIVE DETAILS: ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 9 of 10 Revised 3/2022 PERSONAL REFERENCES: LIST THREE PERSONS WHO KNOW YOU WELL ENOUGH TO PROVIDE CURRENT INFORMATION ABOUT YOU. DO NOT LIST FAMILY MEMBERS OR CURRENT OR FORMER EMPLOYERS: NAME: ADDRESS: CITY/STATE/ZIP: OCCUPATION: RELATIONSHIP: HOMPE PHONE: BUSINESS PHONE: E-MAIL ADDRESS: NAME: ADDRESS: CITY/STATE/ZIP: OCCUPATION: RELATIONSHIP: HOMPE PHONE: BUSINESS PHONE: E-MAIL ADDRESS: NAME: ADDRESS: CITY/STATE/ZIP: OCCUPATION: RELATIONSHIP: HOMPE PHONE: BUSINESS PHONE: E-MAIL ADDRESS: MISCELLANEOUS INFORMATION: DO YOU OR YOUR SPOUSE HAVE A RELATIVE CURRENTLY EMPLOYED BY PARK COUNTY? YES NO IF YES, GIVE THE NAME, RELATIONSHIP, AND POSITION OF THE RELATIVE. IF YOU HAVE PREVIOUSLY WORKED FOR ANY EMERGENCY SERVICE PROVIDER (FIRE, POLICE, OR E.M.S.) LIST ANY AND ALL INTERNAL INVESTIGATIONS IN WHICH YOU WERE LISTED AS A PARTY OR WERE THE FOCUS OF ANY INVESTIGATION, GIVE DATES AND DETAILS. USE ADDITIONAL SHEETS IF NECESSARY. ATTACH A DESCRIPTION, IN YOUR OWN WORDS, OF YOUR FREQUENCY AND EXTENT OF USE OF INTOXICATING LIQUORS. IF YOUR RESPONSE TO ANY OF THE ABOVE QUESTIONS IS YES, ATTACH AN ADDITIONAL SHEET AND EXPLAIN. ---PAGE BREAK--- Park County Emergency Communications P.O. Box 129 Fairplay, Co. 80440 Page 10 of 10 Revised 3/2022 EMERGENCY INFORMATION: IN CASE OF INJURY OR OTHER EMERGENCY NOTIFY: NAME: ADDRESS: CITY: STATE: ZIP: DAYTIME PHONE: CELL PHONE: PAGER: AFFIRMATION: By my signature and initials place below, I affirm under the penalty of perjury, that the information provided in this employment application is provided voluntarily, and that it is true and complete. I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment, even if the omission or falsehood does not direct relate to my job or is not discovered for many years. Initial I give permission for a pre-employment physical examination, including drug screening and x- rays, and I consent to the release to Park County Emergency Communications of any and all medical information as may be deemed necessary by the District in judging my capability to do the work for which I am applying. Initial I authorize the investigation of all statements contained in this application. I also authorize Park County Emergency Communications to contact my present employer, past employers and any listed references. Initial I authorize a search of my criminal justice record. Initial I authorize any persons, schools, current employers or organizations named in this application form to provide Park County Emergency Communications with relevant information and opinions that may be useful to the District in making a hiring decision, and I release such persons and organizations from any legal liability for such information. Initial I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time and may be terminated at any time subject to the provisions of the Personnel Policy Manual as the same may be amended. I understand that no person is authorized to change any of the terms mentioned in this employment application form. Initial SIGNED: USUAL SIGNATURE OF APPLICANT DATE NOTE: THIS DOCUMENT IS NOT VALID UNLESS SIGNED BY THE APPLICANT.