Closing Date United States

EMPLOYMENT APPLICATION:

INSTRUCTIONS

Terrebonne Parish Consolidated Government

Thank you for your interest in Terrebonne Parish Consolidated Government! We know applying for a job can be intimidating, so use these instructions to guide you through our application and hiring process.

• Fill out all fields on the application. If something doesn’t apply to you, enter N/A.

• Fill out separate applications if you are applying for multiple jobs with TPCG.

• If filling out by hand, write legibly in blue or black ink (not pencil).

• Resumes will not be accepted in lieu of the applications unless stated in the job notice. However, if you have a resume and/or cover letter handy, attach it to your application!

• Be sure to sign the application where indicated. Submit your application and resume/cover letter (if available) in one of the following ways: We’ll be in touch! Don’t worry. Whether you’re selected for an interview or not, you’ll hear from us. Questions? No problem! Email HR at **********@****.*** or call 985-***-****. TPCG Employment Application – updated 7/14/2022 1

EMPLOYMENT APPLICATION

Terrebonne Parish Consolidated Government

Section 1. PERSONAL

APPLICANT

Name Last Suffix First Middle initial

Mailing Address Street City State Zip

Phone Number Email Address

Louisiana Driver’s License? If yes, provide type,

endorsements, and expiration date.

Type (personal, commercial, etc.) Endorsements Expiration date Yes No

MISCELLANEOUS Attach additional sheets if necessary for this section. Are you at least 18

years of age?

Are you able to submit verification of your

legal right to work in the United States?

Have you ever been accused of unlawful discrimination, including sexual harassment? If yes, attach a separate sheet to explain. An affirmative answer will not necessarily disqualify you. Yes No Yes No Yes No

Have you ever been convicted of a felony? If yes, explain below. A conviction may not disqualify you, but a false statement will. Yes No

Section 2. POSITION

Position Title List the exact position title for which you are applying. Job Number Closing Date Section 3. EMPLOYMENT

Are you presently employed? If yes, may we contact your present employer? What’s your experience with TPCG? Check all that apply. Yes No Yes No Applied before Worked here previously None How were you referred to TPCG?

TPCG.org Facebook Walk-in Employee Referral Other NAME OF EMPLOYEE RELATIONSHIP DEPARTMENT

This application becomes a public record and is subject to disclosure. Terrebonne Parish Consolidated Government is an equal employment opportunity employer and does not discriminate against an applicant because of a person’s race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, genetic information, or any other legally protected characteristic. Section 4. NEPOTISM If a member(s) of your family is(are) currently employed with TPCG, complete this section. If closing date is not listed on the job vacancy notice, leave Closing Date blank. TPCG Employment Application – updated 7/14/2022 2

Section 5. EDUCATION

Applicants may be required to provide proof of diplomas, degrees, transcripts, licenses, certifications, and registrations.

Indicate the highest elementary or secondary grade completed. Did you graduate from high school or receive a GED/HSE? 1 2 3 4 5 6 7 8 9 10 11 12 Yes No

POST-SECONDARY EDUCATION Undergraduate colleges or universities, graduate schools, or technical/vocational/business schools SCHOOL

GRADUATION DATE

or number of credit hours

completed if not finished

TYPE OF

DEGREE OR DIPLOMA

MAJOR AND MINOR FIELDS OF STUDY

Section 6. LICENSES/CERTIFICATIONS

If a license, certification, or other authorization is required for the position for which you are applying, complete this section.

LICENSE / CERTIFICATION

(e.g., RN, PE, CPA, Attorney, etc.)

DATE ISSUED DATE EXPIRES

ISSUED BY AND LOCATION OF ISSUING AUTHORITY

(e.g., State or other authority)

LICENSE NO.

Section 7. SPECIAL TRAINING,

SKILLS, and QUALIFICATIONS

If special job-related training, skills, or experience using machines, office equipment, or software is required for the position for which you are applying, complete this section. Section 8. EMPLOYMENT HISTORY

Start with current/most recent job. Include armed forces and self-employment. Consider changes to position for same employer as separate items. Complete all boxes. EMPLOYER 1 Your current/most recent job.

Name of Business Type of Business Phone Number

Mailing Address Street City State Zip

Dates Employed (month/year)

From: To:

Average hours

worked per

week

Job Title Supervisor’s Name

Base Rate of Pay

Start: Final:

Reason for Leaving

JOB DUTIES

Are the job duties included in an attached document? If no, you must list job duties below. Yes No

TPCG Employment Application – updated 7/142022 3

EMPLOYER 2

Name of Business Type of Business Phone Number

Mailing Address Street City State Zip

Dates Employed (month/year)

From: To:

Average hours

worked per

week

Job Title Supervisor’s Name

Base Rate of Pay

Start: Final:

Reason for Leaving

JOB DUTIES

Are the job duties included in an attached document? If no, you must list job duties below. Yes No

EMPLOYER 3

Name of Business Type of Business Phone Number

Mailing Address Street City State Zip

Dates Employed (month/year)

From: To:

Average hours

worked per

week

Job Title Supervisor’s Name

Base Rate of Pay

Start: Final:

Reason for Leaving

JOB DUTIES

Are the job duties included in an attached document? If no, you must list job duties below. Yes No

EMPLOYER 4

Name of Business Type of Business Phone Number

Mailing Address Street City State Zip

Dates Employed (month/year)

From: To:

Average hours

worked per

week

Job Title Supervisor’s Name

Base Rate of Pay

Start: Final:

Reason for Leaving

JOB DUTIES

Are the job duties included in an attached document? If no, you must list job duties below. Yes No

TPCG Employment Applica on – Pre-Employment Cer fica on and Reference Check – updated 5/12022 EMPLOYMENT APPLICATION:

PRE-EMPLOYMENT CERTIFICATION & REFERENCE CHECK

Terrebonne Parish Consolidated Government

APPLICANT

Name Last Suffix First Middle initial Last 4 digits of Social Security No.

AUTHORIZATION

PRE-EMPLOYMENT CERTIFICATION Read the following statements carefully before signing. 1. I authorize the investigation of all statements contained in this application.

• I understand that falsification, misrepresentation, or omission of facts called for will result in immediate termination from employment or removal of my application from consideration.

• I authorize the Parish to secure information about my experience with former employers, education institutions, and agencies, and for those parties to provide information concerning my experience, releasing all parties from any liability arising there from.

2. If employed by the Parish, I will abide by Parish policies and rules.

• I understand that I will be required to possess a current and valid Louisiana driver’s license if my position requires me to drive in the course of my work.

3. If I am offered employment, I understand and agree that I may be required to undergo a medical examination at the Parish’s expense and that my offer of employment may be conditioned by that examination.

• I authorize the release of all results or information obtained from such medical examinations to an appropriate Parish representative.

4. If I am offered employment, I understand and agree that I will be required to undergo a drug and/or alcohol test at the Parish’s expense and that my offer of employment may be conditioned by the results.

• I authorize the release of all results or information obtained from such drug and/or alcohol testing to an appropriate Parish representative.

5. If I am offered employment, I authorize the release of my adult criminal history record. 6. I understand and agree that unlawful harassment, whether on the basis of a person’s race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, genetic information, or any other legally protected characteristic as defined by U.S. Equal Employment Opportunity Commission, will not be tolerated. My signature below indicates that I have read and understand this form and to the best of my knowledge and belief, the information on this application is true and correct. My signature also certifies that I agree to be bound by the terms and conditions stated in this application. This application contains all the understandings and agreements between the Parish and me concerning the nature of my employment and supersedes all prior and/or contemporaneous practices, oral or written agreements, understandings, statements, representations, and promises, expressed or implied, between the Parish and me. I understand and agree that, except as noted above, no person who is either an agent or employee of the Parish may modify, delete, vary, or contradict, whether orally or in writing, the terms and conditions of employment set forth herein. AUTHORIZATION TO CONTACT

CURRENT EMPLOYERS Read the following statements carefully. Check the boxes to indicate your authorization. I authorize Terrebonne Parish Consolidated Government to make inquiries of current employers concerning my existing employment, including job performance. I further authorize all current employers providing references to respond to verbal and written inquiries from Terrebonne Parish Consolidated Government regarding my current employment, including job performance. PAST EMPLOYERS Read the following statements carefully. Check the boxes to indicate your authorization. I authorize Terrebonne Parish Consolidated Government to make inquiries of all my past employers, educational institutions, and references concerning my prior employment, including job performance and/or reasons for separation, the verification of my educational background, and personal character. I further authorize all past employers, educational institutions, and all other individuals providing references to respond to verbal and written inquiries from Terrebonne Parish Consolidated Government regarding my past employment, including job performance and/or reasons for separation, the verification of my educational background, and personal character. SIGNATURE

Applicant Signature Date

Contact this candidate