Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

The applicant understands that neither this document nor any offer of employment from the employer constitutes an employment contract unless a specific document to that affect is executed by the employer and employee in writing.

In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the employer.

You are not required to disclose information about physical or mental limitations that you believe will not interfere with your capability to do the job. On the other hand, if you want the employer to consider special arrangements to accommodate a physical or mental impairment, you may identify that impairment in the space provided and suggest the kind of accommodation that you believe would be appropriate.

Impairment   
Suggested Accommodation   

East Feliciana Communications District
APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, disability or any other legally protected status. The East Feliciana Communications District is an Equal Opportunity Employer.
Date of Application:
 

Position (s) applied for:
 

Are you related to any of the appointed officials to the East Feliciana Communications District Board, the Communications District's Executive Director or Assistant Director?

Yes

No

If yes, indicate who and the nature of your relationship:

First Name
Middle Name
Last Name
Address
	City  State  Zipcode
Telephone
Alternate Telephone
Social Security Number

Are you 18 yo or older and posses a valid highschool diploma or GED?

Yes

No

Are you employed now?

Yes

No

May we contact your present employer?

Yes

No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment.)

Yes

No

On what date would you be available to begin work if offered?


Are you available to work

Full Time

Part Time

Shift Work

Temporary

Are you on a lay off and subject to recall?

Yes

No

Have you ever been convicted of any traffic violations?

Yes

No

Have you ever been known by any alias (other name) different then the name you listed above? This includes maiden name, well known nickname, and/or birth name or other if you have had your name legally changed to the indicated name above

AUTHORIZATION TO RELEASE INFORMATION

I respectfully request and authorize you to furnish the East Feliciana Communications District with any and all information that you may have concerning me, my employment, educational records, reputation, criminal history, driving history, financial and credit status. Please include any and all information that may be of a confidential or privileged nature. Your cooperation in this reply will be used to assist the Communications District in determining my qualifications for the position I am seeking with the Communications District. This information that you furnish the Communications District will be used only for determination of employment in a position within the Communications District.

I hereby release you, your organization and others furnishing information from any liability or damage which may result from furnishing the information requested.

I understand that many positions require the incumbent to drive a vehicle of the Communications District. I authorize the Communications District to verify information on my capacity to operate a vehicle. I further consent to the release of information concerning my driving record by the East Feliciana Sheriff's Office, other law enforcement agencies, previous employers and other individuals and agencies, to the Personnel representative of the East Feliciana Communications District.

Applicant's Name (Print Clearly) __________________________________________
Applicant's Signature __________________________________________	Date __________________________________________
Witness __________________________________________	Date __________________________________________

Please print and sign this page.  You must phsyically sign this document and submit it to our office.

(Note: A photocopy reproduction of this request shall be for all intents and purposes as valid as the original. You may retain this form for your files.)

East Feliciana Parish
Communications District
PRE-EMPLOYMENT INFORMATION

As a possible future employee of the East Feliciana Communications District, please read and acknowledge the following information:
(a) False information or statements, inaccuracies and omissions of information on any forms may prevent your employment or may result in disciplinary action including that of immediate termination after hiring.
(b) You may be required to take a physical exam and drug screening after you have been offered conditional employment with the East Feliciana Communications District.
(c) If hired, you will be subject to a minimum three (3) month probationary period. During this probation you will be evaluated as to your performance for employment, attitude and work ethics. The Communications District reserves the right to terminate your employment during this probationary period for any just cause including evidence presenting itself as to your unsuitability for the position, or the positive or questionable result(s) of drug testing indicates use or potential misuse of a controlled legal or illegal substance.

AUTHORITY FOR RELEASE OF INFORMATION

I have read and understand the above statements. I authorize the East Feliciana Communications District to verify any information contained in my application for employment. I further consent to the release of information concerning my capacity to work by employers, law enforcement agencies, and other individuals and agencies, to the Personnel representative of the East Feliciana Communications District. This authorization extends to background checks and interviews with previous employers and others relating to my competence and character.

Applicant's Name (Print Clearly) __________________________________________
Applicant's Signature __________________________________________	Date __________________________________________
Witness __________________________________________	Date __________________________________________

Please print and sign this page.  You must phsyically sign this document and submit it to our office.