Fillable City of Lake City Public Safety (City of Lake City)

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City of Lake City Public Safety (City of Lake City)

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The City of Lake City Public Safety (City of Lake City) form is 8 pages long and contains:

  • 3 signatures
  • 14 check-boxes
  • 160 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Lake City

BROWSE CITY OF LAKE CITY (SC) FORMS
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City of Lake City Public Safety
Name: Date: ________________
City
of Lake City Public Safety
Employment Process
Personal History Questionnaire
Firefighter
Full-Time
Extra-Duty
Volunteer
Police Officer
202 Kelley Street
Lake City, SC 29560
233 N. Acline Street
Lake City, SC 29560
If applying for firefighter, drop off completed
application to: Drew Godwin, LCFD
If applying for Police Officer, drop off completed
application to: Kimberly Shaw, LCPD
If applying for firefighter, drop off completed
application to: Drew Godwin, LCFD
Full-Time
Reserve
Constable
City of Lake City Public Safety
Name: Date: ________________
Please Read These Instructions First!
INSTRUCTIONS TO APPLICANT
This Personal History Questionnaire is part of the initial phase of the employment process
and must be completed by the applicant; all information must be PRINTED IN INK OR
TYPED.
It is imperative that all questions are answered in detail.
• This information will be used by City of Lake City Public Safety for the
employment process.
• The intentional omission or falsification of any material fact is just cause for
disqualification or dismissal of a candidate.
• Personal History Questionnaire. If you have served in the military, include a copy
of
your DD 214 with the questionnaire.
You must answer every question in this Personal History Questionnaire. If a category or
que
stion does not apply, place N/A (Not Applicable) in the designated area. Attach
additional pages if there is insufficient space for your answers.
NOTE: This check sheet provides a list of all required documents that must be submitted with the Personal
History Questionnaire to the City of Lake City Public Safety. A complete Personal History Questionnaire
must be submitted along with photocopies of the following documents, except where an original/certified
document is specifically indicated. (We will not accept individual documents; please send ALL requested
documents in one packet). An incomplete Personal History Questionnaire will halt any further
consideration of your application for the position. No items will be accepted via fax or email.
1. Authorization to Obtain Information
2. Proof of High School Graduation or GED
3. Proof of College Credits/Degree (If applicable) DMV Record from State of your current valid driver’s license –
(send original driving record document from DMV to Lake City Fire Department along with other documents requested
on this check sheet.)
4. Candidate Physical Ability Test (CPAT) Certification/Documentation - Only complete #6 if IAFF CPAT
certification issued by another jurisdiction and is within 6 months of date of employment.
5. Attach a copy of all Police, Fire, EMS, trade or mechanical certifications to the back of this form.
Please list all certifications on page 7.
City of Lake City Public Safety
Name: Date: ________________
City of Lake City Public Safety
AUTHORIZATION TO OBTAIN/RELEASE INFORMATION
I authorize the City of Lake City Public Safety to perform a background investigation in connection with my application for
employment. This investigation may include information as to my criminal history, credit, schools attended, police
convictions, Division of Motor Vehicles’ records, personal references, professional references, previous employers, present
employer, physicians’ records, medical records and other appropriate sources.
I authorize the release of any information that the City of Lake City Public Safety may request from the above sources.
I understand and agree that all information received by City of Lake City Public Safety regarding this application and
background investigation is confidential and shall not be disclosed to me.
Signature: ______________________________________ Date: _______________________________________
Print Name: ____________________________________ Date of Birth: _______________________________
Social Security #: ________________________________ Driver’s License #: ___________________________
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City of Lake City Public Safety
Name: Date: ________________
PERSONAL HISTORY
Instructions: Responses must be typed or printed in black ink. If additional space is needed to answer any
question, entry should be continued on a separate sheet(s) of paper. No spaces are to be left blank; if a
section does not apply, fill in "N/A" (not applicable).
NAME:
Last First Middle
ADDRESS:
Street City State Zip Code
TELEPHONE:
Home: ( ) - Work/Cell: ( ) -
E-MAIL ADDRESS:
DRIVERS LICENSE NO
:
STATE: CLASS:
EXPIRATION DATE:
COMMUNITY CONNECTIONS
City of Lake City Public Safety seeks to develop our workforce from within our community.
1. Did you graduate from Lake City High School or Carolina Academy? Yes ______ No______
2. Are you a resident of Lake City? (Lake City Mailing Address) Yes______ No______
3. If yes, how many years as resident of Lake City? _______
4. Do you currently work for a public or private employer in Lake City? Yes______ No______
City of Lake City Public Safety
Name: Date: ________________
EMPLOYMENT HISTORY
List all employment in chronological order beginning with your present employer and going back 10
years. Include self-employment, part-time and/or periods of unemployment (attach additional sheets, if
necessary.) If you were dismissed from a job or forced to resign, please attach a statement giving
complete details.
FROM (Mo/Yr) /
TO (Mo /Yr)
/
Employer
Supervisor
Address
Reason for Leaving
City, State Zip Code
Telephone
FROM (Mo/Yr)
/
TO (Mo /Yr)
/
Employer
Address
Reason for Leaving
Telephone
FROM (Mo/Yr)
/
TO (Mo /Yr)
/
Employer
Supervisor
Address
Reason for Leaving
City, State Zip Code
Telephone
Supervisor
City, State Zip Code
City of Lake City Public Safety
Name: Date: ________________
REFERENCES
In the space below, please list three references, not including relatives. Please provide at least two phone
numbers and an email address for each reference.
Name
Address where person can be contacted
(include City, State, Zip Code)
Contact information
Primary Number:
Secondary Number:
Email Address:
Primary Number:
Secondary Number:
Email Address:
Primary Number:
Secondary Number:
Email Address:
Please inform the listed references that City of Lake City Public Safety may contact them at any time
during the employment process. Please sign that we have your authorization to contact the above
references at any time.
__________________________________________
Signature
EDUCATION
City of Lake City Public Safety values post-secondary education and life-long professional development.
Achievement in higher education demonstrates an individual’s capacity to think critically, communicate
clearly, work independently and solve complex problems. Begin with the school most recently attended
and end with the last high school attended. Please provide month and year when specifying dates. If no
diploma or degree received please provide the number of credits. Please attach proof of degree.
School Name
Location
(City, State, Zip)
Attendance
From (Mo/Yr) -
To (Mo/Yr)
Type of
Diploma/Degree
Received
Graduation
Date
Credit
Hours
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City of Lake City Public Safety
Name: Date: ________________
SKILLS/CERTIFICATIONS
In addition to placing a high value on formal education, City of Lake City Public Safety also recognizes the
inherent value-added to our profession of the skilled trades such as plumber, electrician, HVAC
technician, licensed contractor, welder and many others. Please list any trade certification or licensure you
possess including any Police, Fire and EMS certifications.
Name Skill or Trade
Name of Technical School and
Location City, State and Zip Code
Skill Level
Certification
Date of Completion of
Certification Training
COMMUNITY INVOLVEMENT
As a community-oriented organization, City of Lake City Public Safety values community involvement by
our members. Please list any community organizations to which you belong or have previously belonged.
(Attach additional page(s) if necessary).
Name of Organization
Address
From
To
City of Lake City Public Safety
Name: Date: ________________
LEADERSHIP ACTIVITIES
City of Lake City Public Safety values the ability to direct, to lead and motivate others. Please list any
formal leadership positions you have held in the professional, educational or community setting. (Attach
additional page(s) if necessary).
Name of Organization
Address
From
To
PERSONAL HISTORY CERTIFICATION STATEMENT
I _________________________________hereby certify that the statements made by me in this Personal History
Questionnaire are true and complete to the best of my knowledge. I understand that any willful misstatements or
material omissions in this application will be sufficient cause to disqualify me from employment consideration
with the City of Lake City Public Safety. If such misstatements or omissions are found after employment, it
will be considered grounds for dismissal. I understand that this completed application and any materials
submitted with it are property of the City of Lake City Public Safety and will not be returned. In the case of a
panel interview, I authorize my application to be viewed by members of the panel.
DATE: ______________ SIGNATURE: ____________________________________________________________
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Completed 26 May 2021

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