Lynchburg fire department

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Firefighter/EMT Personal History Statement

Virginia is an ‘Employment At Will’ state. The City of Lynchburg is an equal opportunity employer. The City of Lynchburg maintains and promotes equal opportunity for all employees and applicants for employment in accordance with relevant state and federal laws. All information is for background investigation purposes for employment consideration. The pre-employment process may be terminated at any point. Failure to complete the application, failure to meet stated deadlines, illegible signatures, or discovery of false information could be reason to terminate the application process.


  1. Begin typing in the “date” highlighted area. Tab to each highlighted area to complete the application. Type or neatly print information specified. Read the application carefully. There are multiple places where your signature is required. Illegible signatures on any form could be reason to disqualify you from the process. If additional space is needed, you may use separate sheets. If a separate sheet is used be certain you reference the section of the application that is being continued. Do not mis-state or omit material facts since the statements made herein are subject to verification to determine your qualifications for employment.

  2. This Firefighter/EMT Personal History Statement is to be accompanied by copies of:
  • Copy of birth certificate or other legal document to verify citizenship (This is for verification of citizenship only.)

  • Copy of High School and College Transcripts.

  • Five reference letters.

  1. Three may be from a personal associate (no relatives)

  2. Two must be from a professional association

  1. You must have a signed and notarized copy of the enclosed “Lynchburg Fire Department Authorization for Release of Information Agreement” returned with your Personal History Statement.

  2. You must complete and sign the FirstPoint Applicant Authorization Forms

  3. Provide copies of any certificates or training records relevant to your qualifications

  • Provide your EMS Certification Number:      

  • Provide your EMS affiliation:      

  • You agree that we may use your EMS Certification Number and affiliation to verify your current EMS certification status:      


  1. Attach answers to the enclosed essay question.

  2. Sign and date the Personal History Statement

  3. The completed Personal History Statement must be returned by Friday, January 24, 2014 (no later than 5:00 pm). The completed packet may be hand-delivered to one of the following persons at Fire Administration: Ann Jenkins, Megan Signor, Michelle Kuhn or Tammy Sage.

If you have any questions, please contact:

Acting Battalion Chief Allen Carwile

(434) 455-6340 ext. 6362



Last Name


First Name


Middle Name


Social Security # (REQUIRED)


Phone Number:     



Notify in Case of Emergency – Address & Phone Number:

Present Address:


Are you at least 21 years old? Yes No

List the Names of Persons in the Department with whom you are acquainted and what type of acquaintance (friend, family member etc.)

Name:       Type of Acquaintance:     

Name:       Type of Acquaintance:     

Name:       Type of Acquaintance:     

Name:       Type of Acquaintance:     

Name:       Type of Acquaintance:     

Are you now employed? Yes No If so, where?      

Are you currently a student? Yes No
May the department contact your present employer at this time? Yes No

If no, why?      

(Be advised that at some point before a conditional offer is made, the department will contact your present employer.)

Have you ever served in the US Armed Forces?

Yes No

Rank and Branch of Service:


Date of Induction:


Date of Discharge:      

Type of Discharge:      

Primary Service Duties:


12. Military Reserve Status: Active Inactive Standby
Organization or Unit:


Reserve Obligation, if any:


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