MSCB #1 Personnel Action Form 2010

User Manual: MSCB-Personnel-Action-Form-2010

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Mississippi Fire Personnel Minimum Standards and Certification Board
Personnel Action Form
A Personnel Action Form must be completed for employee new hire information and for volunteer fire fighters taking the
CPAT and Mississippi NFPA 1001-I/II Certification Program. Complete ALL information below and forward to the MSCB
Office within thirty (30) days. NOTE: Please attach copies of all NFPA 1001 certifications to the Personnel Action Form.
Social Security Number
(Last 4 digits required)

Today’s Date:

Career Fire Fighter

Volunteer Fire Fighter

Date of Current Employment:

Date of Entry:

Full Time or Part Time Status:
Employee’s First Name

M.I.

Last Name

Date of Birth

Street Address:
City:

State:

Zip Code:

Phone Number:

Fire Department Name & Address

Fire Chief/Director

Fire Department Phone Number

Does the employee possess an NFPA 1001- I & II certification? ( ) Yes
Is the certification from in-state or out-of-state?
( ) In-State
Is the certification IFSAC, Pro Board, or MSCB?
( ) IFSAC
( ) MSCB

(
(
(
(

Fire Department Fax Number

) No
) Out-of-State
) Pro Board
) None

Fire Department (Career and Volunteer) Work History: (use attachments if necessary)
Dept. Name/Address/Phone #/Name of Contact/Dates of Employment

Has the employee been separated from the Fire Service?
1. Under two (2) years?
( ) Yes ( ) No
2. Two (2) to Five (5) years? ( ) Yes ( ) No
3. Over (5) years?
( ) Yes ( ) No
______________________________________________
(Signature of Fire Chief/Director or Designee)

____________________________________
Date

WARNING: Mississippi Code as Annotated 97-7-10 Fraudulent statements and representations provide for severe penalties
from misrepresentation or fraudulent statements to a board. This statute authorizes a fine of up to ten thousand dollars
($10,000) and a jail sentence of up to five (5) years.
Mississippi Code 1972 as Annotated §45-11-253 empowers the Board to require the submission of reports and information by
fire service agencies for the administration of §45-11-251 and §45-11-253.
Minimum Standards & Certification Board #1 Fire Academy USA, Jackson, MS 39208-9600
Tel: 601-932-2444
www.mid.state.ms.us/minstand Fax: 601-932-2819
MSCB Form – 1

01/2010 Rev.
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