RECORD OF EMPLOYMENT:
Place an X by the employer(s) you do not want us to contact. List positions starting with most recent:
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Employer: _____________________________________________ Telephone: _____________________________
Address: ________________________________________________________________________________________
Position Title: __________________________________ Supervisor: ________________________________________
Start Date: _________ Date Left: __________ Beginning Salary: __________ Ending Salary: __________
Duties: ________________________________________________________________________________________
Reason for Leaving: ______________________________________________________________________________
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Employer: _____________________________________________ Telephone: _____________________________
Address: ________________________________________________________________________________________
Position Title: __________________________________ Supervisor: ________________________________________
Start Date: _________ Date Left: __________ Beginning Salary: __________ Ending Salary: __________
Duties: ________________________________________________________________________________________
Reason for Leaving: ______________________________________________________________________________
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Employer: _____________________________________________ Telephone: _____________________________
Address: ________________________________________________________________________________________
Position Title: __________________________________ Supervisor: ________________________________________
Start Date: _________ Date Left: ___________ Beginning Salary: _________ Ending Salary: _________
Duties: ________________________________________________________________________________________
Reason for Leaving: ______________________________________________________________________________
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WORK-RELATED REFERENCES: (Do not include relatives)
Name Occupation Contact Information
1. ____________________ _________________ ___________________________________________
2. ____________________ _________________ ___________________________________________
3. __________________ _______________ _______________________________________
STATEMENT (Please read this statement carefully before signing this application):
I understand that employment with Livingston Parish Council is at-will, meaning that I or Livingston Parish Council may terminate
my employment at any time, or for any reason consistent with applicable state or federal law.
I authorize Livingston Parish Council to conduct a thorough background investigation of my work and personal history, and verify all
data given on this application and during interviews. I hereby release the Organization, and its representatives or agents, from any
liability that might result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested
information and release them from all liability for providing the requested information.
I understand that Livingston Parish Council requires the successful completion of a drug and/or alcohol test as a condition of
employment.
I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I
must submit a new application. I certify that all the statements in this completed application are true and understand that any
falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.
Signature of Applicant: ___________________________________ Date Signed: ________________________
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