Fill - Free fillable Contact Information Position applying for: (Please print and (Bossier Parish Community College) PDF form

* Required field

Position applying for: (Please print and attach supplemental questions included in the posting for which you are applying)

*Job Title:___________________________________________________________Job#:______________________

*Agency: *Location:

NOTE: Any Supplemental Questions accompanying this job posting must be printed, answered, and submitted with this application or

your application will be considered incomplete

.

Contact Information

*Name

First Middle Initial Last

*Mailing Address

Street City State Zpi Code

*Email Address

*Home Phone Alternative Phone

*Social Security Number (Full # Required)

*By which method would you prefer to be notified about application status, testing dates and examination results?

(Note: if you select ‘E‐mail,’ you may still continue to receive paper notices from certain employers, depending on

their preference.)

Please check one of the following options: E‐mail

Other Personal Information

Mail

*Do you possess a valid Driver’s License? (Please check one)

Yes, I possess a valid Driver’s License. No, I do not possess a valid Driver’s License.

If Yes, Please provide the State and number

*Class: 1 2 3

4

A

CDL

B B CDL C C CDL CM D

E E (Learner) F M1 M2

Motorcycle R None

I consent to the release of information concerning my capacity and/or all aspects of prior job performance by employers, educational institutions, law

enforcement agencies, and other individuals and agencies to duly accredited investigators, human resources staff, and other authorized employees of the

state government for the purpose of determining my eligibility and suitability for employment.

I certify that all statements made on this application and any attached papers are true and complete to the best of my knowledge. I understand that the

information on this application may be subject to investigation and verification and that any misrepresentation or material omission may cause my

application to be rejected, my name to be removed from the eligible register and/or subject me to dismissal from state service.

I have read the statements above carefully before signing this application:

Signature of Applicant Date

Unclassified

Application

Additional Information

*Can you, after employment, submit proof of your legal right to work in the United States? (Please check one)

Yes No

*Please check the types of employment you will accept: Permanent Temporary

Certificates and Licenses

Type

License Number

Issued By

Date Issued

Date Expires

Additional Skills

*Are you currently at least 18 years old? Yes No

The State of Louisiana requests the information below so we may comply with federal Equal Employment

Opportunity law requirements. The information is strictly voluntary and in no way influences employment

prospects.

Gender: Male Female Decline to state

Ethnicity: Hispanic or Latino Non‐Hispanic or Non‐Latino Decline to state

Race: White/Caucasian Asian American Indian/Alaskan Native

Black or African American Native Hawaiian or other Pacific Islander

2 or more races Decline to state

Date of Birth (Month/Day/Year): / /

How did you find out about this job? Civil Service website Paper announcement at agency

Newspaper ad Flier Career Fair

Please select all that apply to you:

Word of mouth Other

I am a certified Vocational Rehabilitation Client. (Rule 22.8(a))

I have a 3.5 GPA or higher for my baccalaureate degree. (Rule 22.8(c))

I am an active duty member of the armed forces, or a veteran of the armed forces who has served at least

90 days of active service for purposes other than training and who has been honorably discharged from active

duty within the previous 12 months. (Rule 22.8(d))

I am eligible for Non‐competitive Re‐employment. (Rule 23.13)

I am a current permanent classified state employee in a job which requires the same Civil Service test as this

vacancy, and I have been in this job for at least the last six months.

None of the above.

*Are you an Army Pays participant? Yes No

To enable us to fully evaluate any military experience claimed, please list in the space provided below each rank and

grade you have held (e.g., include E, O or W grade) and the date that each was attained. If you do not have any military

experience, enter N/A.

* Are you claiming Veteran’s Preference points on this application? Yes No

If claiming Veteran’s Preference points, were you honorably discharged or discharged under honorable conditions

from the Armed Forces of the United States? Yes No Does not apply

Are you an honorably discharged veteran who served either in peace or in war and who has one or more disabilities

recognized as service‐connected by the Veteran’s Administration? Yes

No

* Required field

During which period did you serve? (check all that apply)

In the wartime period April 6, 1917 through November 11, 1918

In the wartime period September 16, 1940 through July 25, 1947

In the wartime period June 27, 1950 through January 31, 1955

In the wartime period July 1, 1958 through May 7, 1975

In a peacetime campaign or expedition for which campaign badges are authorized

Post 09/11/01 for 90 days or more and for purposes other than training

Does not apply/None of the above

Please select all that apply:

I am the spouse of a veteran whose physical condition precludes his or her appointment to a civil

service job in his or her usual line of work.

I am the unmarried widow of a deceased veteran who served in a war period as defined in the question

above, or in a peacetime campaign or expedition.

I am the un‐remarried widowed parent of any person who died in active wartime or peacetime service or

who suffered total and permanent disability in active wartime or peacetime service.

I am the divorced or separated parent of any person who died in wartime or peacetime service or who

became totally and permanently disabled in wartime or peacetime service.

None of the above

*Are you currently holding or running for an elective public office? Yes

No

*Have you ever been fired from a job or resigned to avoid dismissal? Yes

No

If “Yes”, please explain below. A “Yes” answer will not necessarily bar you from state employment.

*If you are a male from the ages 18 through 25, please answer the following question “Yes” or “No”. If you are not

a male in this group, select “Does not apply”. Are you registered with the Selective Service System?

Yes No Does not apply

In which parishes are you available for employment? Acadia Allen Ascension

Assumption Avoyelles Beauregard Bienville Bossier Caddo

Calcasieu Caldwell Cameron Catahoula Claiborne Concordia

DeSoto E. Baton Rouge E. Carroll E. Feliciana Evangeline Franklin

Grant Iberia

Iberville

Jackson

Jefferson Jeff Davis

Lafayette Lafourche LaSalle Lincoln Livingston Madison

Morehouse Natchitoches Orleans Ouachita Plaquemines Pointe Coupee

Rapides Red River Richland Sabine St. Bernard St. Charles

St. Helena St. James St. John St. Landry St. Martin St. Mary

St. Tammany Tangipahoa Tensas Terrebonne Union Vermillion

Vernon Washington Webster W. Baton Rouge W. Carroll W. Feliciana

Winn

* Required field

Education

*High School Name

Location

Have you received a high school diploma or equivalency certificate? Yes No

Give the name and address of the school, major course of study, and degree achieved:

Undergraduate University Graduate School

College Major Area of Study

Degree Attained Degree Attained

Year Year

Undergraduate Semester

Hours Completed

Undergraduate Quarter

Hours Completed

Graduate Semester Hours

Completed

Graduate Quarter Hours

Completed

Work History

Describe your work experience, beginning with your current or most recent job. Include military service,

volunteer work, self‐employment, and part‐time employment.

1. Name of Present or Last

Employer

Job Title _

Address

_ _

Phone Supervisor

From (Month/Year) / To / Hours Per Week

Salary Number of Employees Supervised

May we contact this employer? Yes No

Job Duties (give details)

Reason For Leaving

2. Your Next Most Recent

Employer

Job Title _

Address

Phone _ __ Supervisor

From (Month/Year) / To / Hours Per Week

Salary Number of Employees Supervised

May we contact this employer? Yes No

* Required field

Job Duties (give details)

Reason For Leaving

3. Your Next Most Recent

Employer

Job Title _

Address

Phone _ __ Supervisor

From (Month/Year) / To / Hours Per Week

Salary Number of Employees Supervised

May we contact this employer? Yes No

Job Duties (give details)

Reason For Leaving

4. Your Next Most Recent

Employer

Job Title _

Address

Phone _ __ Supervisor

From (Month/Year) / To / Hours Per Week

Salary Number of Employees Supervised

May we contact this employer? Yes No

Job Duties (give details)

Reason For Leaving

5. Your Next Most Recent

Employer

Job Title _

Address

Phone _ __ Supervisor

From (Month/Year) / To / Hours Per Week

Salary Number of Employees Supervised

May we contact this employer? Yes No

Job Duties (give details)

Reason For Leaving

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Fill Online, Printable, Fillable, Blank Contact Information Position applying for: (Please print and (Bossier Parish Community College) Form

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