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LAFAYETTE FIRE AND POLICE CIVIL SERVICE BOARD REQUIREMENTS (Lafayette City-Parish Consolidated Government)

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LAFAYETTE FIRE AND POLICE CIVIL SERVICE BOARD
REQUIREMENTS FOR COMPLETING APPLICATIONS TO COMPETITIVE
EXAMINATIONS
1. NOTE THE DEADLINE FOR RECEIPT OF APPLICATIONS, YOU MUST
RETURN THE COMPLETED FORM WITH ALL REQUIRED
DOCUMENTS BEFORE THE DEADLINE.
2.
YOU MUST PROVIDE COPIES OF THE FOLLOWING ITEMS WHEN
YOU SUBMIT YOUR APPLICATION FORM. THE CIVIL SERVICE
OFFICE CANNOT MAKE COPIES FOR YOU.
a. IF YOU ARE CLAIMING TO BE POST CERTIFIED, A COPY
OF YOUR POST CERTIFICATION.
b. SOCIAL SECURITY CARD
c. PROOF OF BIRTH DATE (BIRTH CERTIFICATE OR
CERTIFICATE OF BAPTISM)
d. HIGH SCHOOL DIPLOMA OR GED CERTIFICATE
e. VALID DRIVER’S LICENSE
f. IF YOU ARE CLAIMING VETERAN’S PREFERENCE, A DD
214 SHOWING HONORABLE DISCHARGE. WE MUST SEE
YOUR DISCHARGE FORM DD 214 IN ORDER FOR 5 POINTS
TO BE ADDED TO YOUR TEST SCORE. THE 5 POINTS ARE
ADDED ONLY IF YOU PASS THE TEST. NINETY
CONSECUTIVE DAYS OF ACTIVE DUTY AND AN
HONORABLE DISCHARGE ARE PREREQUISITE TO
RECEIVE VETERAN’S PREFERENCE.
APPLICATIONS CANNOT BE ACCEPTED UNTIL ALL THE ABOVE
REQUIREMENTS ARE MET!!!
APPLICATION FOR COMPETITIVE EXAMINATION
FIRE AND POLICE CIVIL SERVICE BOARD
PLEASE PRINT OR TYPE. FAILURE TO ANSWER ALL QUESTIONS IN THIS APPLICATION MAY CAUSE YOUR APPLICATION
TO BE DELAYED OR REJECTED.
NAME: FIRST MIDDLE LAST
STREET ADDRESS/P.O. BOX NO. CITY/TOWN STATE/ZIP
HOME TELEPHONE NUMBER (WITH AREA CODE)
OFFICE TELEPHONE NUMBER (WITH AREA CODE)
()
()
SOCIAL SECURITY NUMBER DATE OF BIRTH
MONTH/DATE/YEAR:
ARE YOU A CITIZEN OF THE UNITED STATES?
ARE YOU A REGISTERED VOTER OF THE STATE OF LOUISIANA?
YES NO YES NO
TITLE OF POSITION FOR WHICH YOU ARE APPLYING (FILE A SEPARATE APPLICATION FOR EACH TYPE OF POSITION)
Black
/
3. 4. 5.
RACE/SEX INFORMATION
The Federal government requires that we request the following race and sex information for statistical reporting purposes.
Completion of this section is voluntary, and your application will not be rejected if you choose not to provide this
information.
Male
Female
White Hispanic Am. Indian Asian
Other:
SPECIAL INSTRUCTIONS FOR DOCUMENTATION WHICH SHOULD BE ATTACHED TO YOUR
COMPLETED APPLICATION FOR EXAMINATION
So that our civil service board may evaluate your qualifications for admission to the examination, please attach a copy
of the documents checked below to your completed application:
VOTER REGISTRATION CARD
HIGH SCHOOL DIPLOMA OR GED EQUIVALENCY CERTIFICATE
DRIVERS LICENSE
COLLEGE TRANSCRIPT, IF APPLICABLE
SPECIAL CERTIFICATIONS OR LICENSES REQUIRED FOR ADMISSION TO SPECIFIC CLASSES
AUTHORITY FOR RELEASE OF INFORMATION
I HAVE COMPLETED THIS APPLICATION WITH THE KNOWLEDGE AND UNDERSTANDING THAT ANY OR ALL ITEMS CONTAINED HEREIN MAY BE
SUBJECT TO INVESTIGATION PRESCRIBED BY LAW, AND I CONSENT TO THE RELEASE OF INFORMATION CONCERNING MY CAPACITY AND FITNESS
BY EMPLOYER, EDUCATIONAL INSTITUTIONS, LAW ENFORCEMENT AGENCIES, AND OTHER INDIVIDUALS AND AGENCIES, TO DULY ACCREDITED
INVESTIGATORS, CIVIL SERVICE BOARD MEMBERS AND OTHER AUTHORIZED EMPLOYEES OF THE GOVERNMENT FOR THAT PURPOSE.
I CERTIFY THAT THE ANSWERS I HAVE GIVEN TO ALL QUESTIONS IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE. I KNOW
THAT ANY MISREPRESENTATION HEREIN MAY CAUSE MY APPLICATION TO BE REJECTED, MY NAME REMOVED FROM THE ELIGIBLE LIST AND OR
MAY SUBJECT ME TO DISMISSAL FROM EMPLOYMENT.
DATE SIGNATURE OF APPLICANT
FOR USE OF CIVIL SERVICE BOARD ONLY
Voter Citizen Age Education Vet. Pref.
1. CHM 2. V. CHM
-1-
1.
NO
NO
NO
WITHIN THE PAST 5 YEARS, HAVE YOU BEEN TERMINATED, OR RESIGNED IN LIEU OF TERMINATION, FROM ANY POSITION FOR REASONS OTHER
THAN A REDUCTION IN FORCE?
YES
NOTE: IF YOU ANSWER "YES" TO THIS QUESTION, PLEASE PROVIDE AN EXPLANATION IN THE EXPLANATION BLOCK PROVIDED BELOW.
BACKGROUND INFORMATION
IF YOU ARE APPLYING FOR A JOB WHICH REQUIRES THE ABILITY TO DRIVE A VEHICLE, PLEASE PROVIDE YOUR DRIVER'S LICENSE NUMBER:
DRIVER'S LICENSE NUMBER & ISSUING STATE:
2. HAVE YOU EVER BEEN CONVICTED OF A FELONY?
YES
3. HAVE YOU BEEN CONVICTED OF A MISDEMEANOR DURING THE LAST 3 YEARS?
YES
NOTE: IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE QUESTIONS, PLEASE PROVIDE AN EXPLANATION IN THE EXPLANATION BLOCK BELOW.
A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM THE JOB FOR WHICH YOU ARE APPLYING. A CONVICTION WILL BE JUDGED ON
ITS OWN MERITS WITH RESPECT TO TIME, CIRCUMSTANCES, AND SERIOUSNESS.
EXPLANATION. PLEASE USE THE SPACE PROVIDED BELOW TO EXPLAIN ANY "YES" ANSWERS TO THE ABOVE THREE QUESTIONS. ATTACH
ADDITIONAL PAGES IF NECESSARY.
TRAINING/EDUCATION
A. HIGH SCHOOL
DIPLOMA OR EQUIVALENCY CERTIFICATE
DATE RECEIVED:____________________________________
I DID NOT GRADUATE, BUT COMPLETED GRADE:__________
B. COLLEGE
NAME OF COLLEGE OR UNIVERSITY/LOCATION
NAME AND ADDRESS OF HIGH SCHOOL ISSUING DIPLOMA OR OF STATE DEPARTMENT OF
EDUCATION ISSUING GED OR EQUIVALENCY CERTIFICATE:
YEARS CREDIT
DEGREE(S) DATE OF MAJOR
ATTENDED HOURS
RECEIVED DEGREE
EARNED
-2-
Name:
Address:
City:
State:
Zip Code:
Name:
Location:
Name:
Location:
Name:
Location:
Name:
Location:
Name:
Location:
YES
NO
YES
NO
YES
NO
including an
C. OTHER FORMAL TRAINING (BUSINESS, TRADE, MILITARY, ETC.,
CLASSES OR SEMINARS)
TITLE OF INSTRUCTION OR CLASS (ATTACH ADDITIONAL PAGES IF NECESSARY)
LOCATION DATES
ATTENDED
DID YOU
GRADUATE?
NO. OF HOURS
PER WEEK
SPECIAL QUALIFYING EXPERIENCE, CERTIFICATIONS, OR LICENSES
PLEASE LIST BELOW ANY PROFESSIONAL LICENSES OR CERTIFICATIONS THAT ARE RELEVANT TO THE JOB FOR WHICH YOU ARE APPLYING.
(ATTACH ADDITIONAL PAGES IF NECESSARY)
NO. 1 NO. 2 NO. 3
NAME OF LICENSE OF TYPE OF CERTIFICATION
NAME AND COMPLETE ADDRESS OF AGENCY
OR INSTITUTION ISSUING LICENSE OR
CERTIFICATION
DATE LICENSE OR CERTIFICATION ACQUIRED
EXPIRATION DATE, IF APPLICABLE
RESTRICTIONS, IF APPLICABLE
LIST ANY SPECIAL COURSE WORK, TRAINING, OR EXPERIENCE WHICH MAY BE BENEFICIAL IN THE JOB FOR WHICH YOU ARE APPLYING, OR WHICH
MAY SATISFY ANY SPECIAL QUALIFICATION REQUIREMENTS.
IF YOU HAVE COMPUTER EXPERIENCE, PLEASE LIST ANY SOFTWARE PACKAGES OR COMPUTER LANGUAGES WITH WHICH YOU HAVE A WORKING
KNOWLEDGE:
TYPING ABILITY:
WPM
VETERAN'S PREFERENCE
Five-point veteran’s preference is granted to veterans who receive passing scores for an entrance class and who were
discharged under honorable conditions from active duty in the U.S. Armed Forces during a war, or in a peacetime
campaign or expedition for which a campaign badge has been authorized, including the following wartime periods:
06/27/50 - 01/31/55 (Korean Conflict); during the period of more than 180 consecutive days, any part of which occurred
between 01/31/55 and 10/15/76 (including the Vietnam era), not including active duty for training in Reserves or National
Guard; and from 08/02/90 - 01/02/92 (Gulf War). If your service began after October 15, 1976, you must have received a
Campaign Badge, or Expeditionary Medal. Campaigns or expeditions for which such medals have been authorized include
El Salvador, Lebanon, Granada, Panama, Southwest Asia, Somalia, Haiti, Kosovo, Bosnia and Herzegovina. Medal holders
and Gulf War veterans who originally enlisted after September 7, 1980, (or began active duty on or after October 14, 1982,
and have not previously completed 24 months of continuous active duty) must have served continuously for 24 months
or the full period called or ordered to active duty. Note: If your DD-214 does not provide proof of entitlement for
preference, you must obtain an amended DD-214 or other written documentation showing award of Armed Forces
Expeditionary Medal.
Should you wish to receive the veteran’s preference points, check the space provided and attach a copy of your DD-214
which verifies your qualification to receive preference.
I QUALIFY FOR THE FIVE-POINT VETERAN'S PREFERENCE AS IDENTIFIED ABOVE, AND HAVE ATTACHED A COPY
OF MY DD-214 OR OTHER DOCUMENTATION TO THIS APPLICATION FOR VERIFICATION PURPOSES
REQUEST FOR TESTING ACCOMMODATIONS UNDER THE AMERICANS WITH DISABILITIES ACT
If you require any special testing accommodations because of a disability which limits a major life activity, you must
complete this section in order for your request to be considered.
I am requesting testing accommodations under the Americans With Disabilities Act for the following disability (check
box and specify disability):
Required documentation to attach to your application: IN ORDER FOR THIS CIVIL SERVICE BOARD TO PROCESS YOUR
ADA REQUEST, you must attach recent written documentation of your disability, assessment of
accommodations which might be appropriate to compensate for your disability in a testing environment, prepared by a
DOCTOR, PSYCHOLOGIST, REHABILITATION COUNSELOR, OCCUPATIONAL or PHYSICAL THERAPIST, or OTHER
PROFESSIONAL with knowledge of your functional limitations.
The required documentation is attached to this application.
-3-
WORK EXPERIENCE
INSTRUCTIONS FOR COMPLETING SECTION ON WORK EXPERIENCE
Start with your present or most recent position and work back, including any military experience.
Use separate blocks if you were promoted or your duties changed materially while working for the
same employer. Treat each change as a separate position. For volunteer experience, use work
experience blocks and disregard reference to salary. It is to your advantage to completely describe
your duties in each position, placing particular emphasis on duties, tasks performed, and
responsibility. Attach additional pages, if necessary.
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT WAS THIS AVERAGE NUMBER OF BEGINNING ENDING
FULL-TIME HOURS WORKED PER SALARY SALARY
FROM: TO:
EMPLOYMENT? WEEK:
MO. DAY YR. MO. DAY YR.
G YES G NO
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER/TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT WAS THIS
FULL-TIME
FROM: TO:
EMPLOYMENT?
AVERAGE NUMBER OF BEGINNING ENDING
HOURS WORKED PER SALARY SALARY
WEEK:
MO. DAY YR. MO. DAY YR.
G YES G NO
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER/TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
-4-
Address:
Zip Code:
Name:
Title:
Number:
Title:
Address:
State:
Name:
Title:
Number:
Title:
TO:
YR.
G G NO
/
TO:
YR.
G G NO
/
TO:
YR.
G G NO
/
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT
FROM:
WAS THIS
FULL-TIME
EMPLOYMENT?
AVERAGE NUMBER OF
HOURS WORKED PER
WEEK:
BEGINNING
SALARY
ENDING
SALARY
MO. DAY MO. DAY YR.
YES
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT
FROM:
WAS THIS
FULL-TIME
EMPLOYMENT?
AVERAGE NUMBER OF
HOURS WORKED PER
WEEK:
BEGINNING
SALARY
ENDING
SALARY
MO. DAY MO. DAY YR.
YES
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT
FROM:
WAS THIS
FULL-TIME
EMPLOYMENT?
AVERAGE NUMBER OF
HOURS WORKED PER
WEEK:
BEGINNING
SALARY
ENDING
SALARY
MO. DAY MO. DAY YR.
YES
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
-5-
Name:
Title:
Number:
Title:
State:
Name:
Title:
Number:
Title:
State:
Name:
Title:
Number:
Title:
TO:
YR.
G G NO
/
TO:
YR.
G G NO
/
TO:
YR.
G G NO
/
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT
FROM:
WAS THIS
FULL-TIME
EMPLOYMENT?
AVERAGE NUMBER OF
HOURS WORKED PER
WEEK:
BEGINNING
SALARY
ENDING
SALARY
MO. DAY MO. DAY YR.
YES
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT
FROM:
WAS THIS
FULL-TIME
EMPLOYMENT?
AVERAGE NUMBER OF
HOURS WORKED PER
WEEK:
BEGINNING
SALARY
ENDING
SALARY
MO. DAY MO. DAY YR.
YES
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
NAME AND COMPLETE ADDRESS OF EMPLOYER TYPE BUSINESS
TITLE OF YOUR POSITION
DATES OF EMPLOYMENT
FROM:
WAS THIS
FULL-TIME
EMPLOYMENT?
AVERAGE NUMBER OF
HOURS WORKED PER
WEEK:
BEGINNING
SALARY
ENDING
SALARY
MO. DAY MO. DAY YR.
YES
NAME AND TITLE OF IMMEDIATE SUPERVISOR NUMBER TITLE(S) OF EMPLOYEES YOU SUPERVISED
DESCRIBE YOUR DUTIES IN DETAIL (USE SEPARATE SHEET, IF NECESSARY)
-6-
Zip Code:
Name:
Title:
Number:
Title:
Zip Code:
Name:
Title:
Number:
Title:
Zip Code:
Name:
Title:
Number:
Title:
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LAFAYETTE FIRE AND POLICE CIVIL SERVICE BOARD REQUIREMENTS (Lafayette City-Parish Consolidated Government)

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Completed 27 January 2021

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