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Emergencies Dial: 911

Employment Application

Home » Employment » Employment Application

Employment Application

- Step 1 of 5

Name *

First

Middle

Last

Other Names Used (Maiden, Married)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone

Home Phone

Height

Weight

Eyes

Hair

Date of Birth *

Place of Birth *

US Citizen *

Yes
No

Position Applied For *

Position Type *

Full Time
Part Time

Relationship Status *

Married
Single
Divorced
Widowed
Separated

Section 2

Spouse's Name *

First

Middle

Last

Date of Birth *

Place of Birth *

Street Address *

Place of Employment *

Business Phone No.

Home Phone No.

Family Records

(Include Children, Father, Mother, Brothers, and Sisters)

Family Member #1

Name, Relationship, Age, Present Address, Occupation

Family Member #2

Name, Relationship, Age, Present Address, Occupation

Family Member #3

Name, Relationship, Age, Present Address, Occupation

Family Member #4

Name, Relationship, Age, Present Address, Occupation

Family Member #5

Name, Relationship, Age, Present Address, Occupation

Family Member #6

Name, Relationship, Age, Present Address, Occupation

Family Member #7

Name, Relationship, Age, Present Address, Occupation

Military Service

Branch

Status

Active
Inactive

Date Entered

Date Seperated

Rank at Time of Separation

Service Awards or Decorations

Type of Discharge

Member of National Guard or Reserve

Yes
No

Employment

List all employers for the last five (5) years beginning with the present or most recent:

May Your Present Employer Be Contacted?

Yes
No

Employment #1

Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Fax No.

Phone No.

Reasons for Leaving

First Date of Employment

Last Date of Employment

Position Held

Employment Type

Full Time
Part Time

Name of Supervisor

First

Last

Beginning Salary

Ending Salary

Description of Duties

Employment #2

Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Fax No.

Phone No.

Reasons for Leaving

First Date of Employment

Last Date of Employment

Position Held

Employment Type

Full Time
Part Time

Name of Supervisor

First

Last

Beginning Salary

Ending Salary

Description of Duties

Employment #3

Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Fax No.

Phone No.

Reasons for Leaving

First Date of Employment

Last Date of Employment

Position Held

Employment Type

Full Time
Part Time

Name of Supervisor

First

Last

Beginning Salary

Ending Salary

Description of Duties

Employment #4

Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Fax No.

Phone No.

Reasons for Leaving

First Date of Employment

Last Date of Employment

Position Held

Employment Type

Full Time
Part Time

Name of Supervisor

First

Last

Beginning Salary

Ending Salary

Description of Duties

Employment #5

Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Fax No.

Phone No.

Reasons for Leaving

First Date of Employment

Last Date of Employment

Position Held

Employment Type

Full Time
Part Time

Name of Supervisor

First

Last

Beginning Salary

Ending Salary

Description of Duties

Residence

List your places of residence for the past five (5) years beginning with your present or most recent:

Address #1 *

Address Line 1

Address Line 2

City

State

Zip Code

Address #2

Address Line 1

Address Line 2

City

State

Zip Code

Address #3

Address Line 1

Address Line 2

City

State

Zip Code

Address #4

Address Line 1

Address Line 2

City

State

Zip Code

Address #5

Address Line 1

Address Line 2

City

State

Zip Code

Address #6

Address Line 1

Address Line 2

City

State

Zip Code

References

DO NOT list relatives or former employers.

Reference #1

Name

First

Last

Relationship

Age

Present Address

Occupation

Reference #2

Name

First

Last

Relationship

Age

Present Address

Occupation

Reference #3

Name

First

Last

Relationship

Age

Present Address

Occupation

Special Skills / Training / Hobbies

Please list the languages (including sign) that you can speak, read, or write:

Language #1 *

Language Skills *

Speak
Read
Write

Language #2

Language Skills

Speak
Read
Write

Please list any skills or training you may have in one or more of the following:

EMT, CPA, Radio Communications, Computer Programmer, and others.

Have you ever been convicted, forfeited collateral, or are you now under investigation for any criminal offense? *

Yes
No

If Yes, please explain:

Are you now on probation or parole? *

Yes
No

If Yes, please explain:

Do you have any relatives employed by the Rapides Parish Communications District? *

Yes
No

If so, list them by name:

Education and Job Related Skills or Courses

Select highest level completed: *

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

High School Name and Location

Dates Attended High School

High School Degree Rec'd

College/University Name and Location

Dates Attended College/University

College/University Degree Rec'd/Major

Business/Trade School Name and Location

Dates Attended Business/Trade

Business/Trade Degree Rec'd/Major

Please list memberships in business, civic, or fraternal organizations:

List here any other qualifications you may wish considered in your application:

I HAVE RECEIVED AND REVIEWED A COPY OF THE JOB CLASSIFICATION FOR THE POSITION WHICH I AM CURRENTLY APPLYING FOR (PLEASE INITIAL) *

Is there any reason you might not be physically capable of performing the duties as described in the job classification received? *

YES
NO

Pre-Employment Inquiry

I, [Applicant Name] the undersigned, agree and acknowledge that I am an applicant for employment with the Rapides Parish Communications District.

I hereby authorize a review and full disclosure of all information and records concerning myself to the Rapides Parish Communications District relative to educational background, employment and pre-employment records, including background reports, efficiency ratings, financial information, criminal and traffic arrest or convictions and any other factors that would be pertinent to my suitability for employment.

I hereby authorize any agency or individual questioned by the Rapides Parish Communications District about my background to release any and all information deemed pertinent by the Rapides Parish Communications District. I hereby release the Rapides Parish Communications District and any other agency or persons from any liability in connection with furnishing such information.

I further understand that I may be required to submit to a physical exam if I am offered employment and hereby authorize review and full disclosure of all information and records concerning myself to the Rapides Parish Communications District relative to my medical and psychiatric treatments and/or consultation. I understand that if deemed necessary an additional HIPAA form will be required.

I further understand that all information obtained as a result of this investigation shall be confidential and in the event my application is rejected, that reason for said rejection shall not be revealed.

Applicant Name *

Signature *

DOB *

911 Public Safety Blvd. Natchitoches, LA

318.357.8300

Emergencies Dial: 911

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