Application for Employment

1 Plaquemines Parish Sheriff's Office8022 Hwy. 23 Belle Chasse, La 70037504-934-6776 Application for EmploymentPrint Neatly or Type this Application : Completed applications must be turned in by the APPLICANT at the Internal Affairs Office at 8397 Hwy. 23, Ste. 102, Belle Chasse. Please do not call to check on the progress of your Application . The Sheriff's Office will notify you when it is time to return for additional must make your own copies and provide the following photostat copies with the Application : 1. Choose one: High School Transcript, High School Diploma, GED Diploma or GED Transcript Scores ** Replacement Options for required Louisiana High School or GED documents ** a. High School Transcript replacement: Public and Private High School - (call) or visit web site b.

2 High School Diploma replacement: Public - Contact the School Board Office for that High School c. High School Diploma replacement: Private - Contact that High School d. GED: Diploma or Transcript Scores replacement: visit web site or call 2. Certified Copy of Birth Certificate - Louisiana replacement: (call) 3. Valid Driver's License - Louisiana Info: visit web site or call 4. Social Security Card - Info: visit web site or call 5. Any other additional education diplomas, certificates or transcripts (if applicable) 6. Discharge/Separation (DD214 and or NGB22) forms for each period of military service (if applicable) 7. Naturalization certificate if you were born outside the United States (if applicable) 8.

3 Please fill out form PC-201 & PC-206 completely, attached to this Application . Leave no blanks on this Application . If questions are not applicable, enter N/A. If questions are unknown, enter UNK. INCOMPLETE applications WILL NOT BE PROCESSEDThe Plaquemines Parish Sheriff's Office is an Equal Opportunity Employer1 of 11**If there is not enough room on the Application for you to provide a complete answer to any of the questions, use an additional piece of paper to do so.**Gerald , Jr., Sheriff**Do Not Attach Resumes'**Revision 05172017 Name: GENERALDATE OF Application :LastPOSITION APPLYING FOR:DEPUTY SHERIFFCOMMUNICATIONS / OPERATOR / DISPATCHER CORRECTIONS OFFICER RESERVE DEPUTYCLERICAL/ SECRETARIALOTHER (Please Specify):WITHI CAN PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB(S) FOR WHICH I AM APPLYINGWITHOUTREASONABLE ACCOMMODATION(S).

4 IF REASONABLE ACCOMMODATION IS NECESSARY, PLEASE SPECIFY:PERSONAL INFORMATIONF irstSUFFIX:LAST NAM E:FIRST NAM E:M ID D L E N AM E:INICKNAMES OR OTHER NAMES I HAVE USED OR AM KNOWN BY: ( Maiden, Change of Name, Nicknames, Alias, etc.)HEIGHT:W EIG HT :DAT E O F BIRT H:HAIR COLOR:EYE COLOR:BIRTHPLACE:SEX:PHYSICAL ADDRESS (Street / City / State / Zip):MAILING ADDRESS (Street / Box / City / State / Zip):SAME AS ABOVEHOME TELEPHONE NO.:DRIVER'S LICENSE:NUMBER:STATE:SOCIAL SECURITY NO.:CONTACT INFORMATION:WORK:PAGER:M O BIL E :MiddleEMAIL: IF APPLICABLE, PLEASE SPECIFY THE COUNTRY OF YOUR CITIZENSHIP:AMA CITIZEN OF THE UNITED NOTCANSUBMIT VERIFICATION OF MY LEGAL RIGHT TO WORK IN THE UNITED NOTP laquemines Parish Sheriff's Office8022 HWY 23 Belle Chasse, La 70037504-934-6776 Application for Employment2 of 11 The Plaquemines Parish Sheriff's Office is an Equal Opportunity EmployerGerald A.

5 Turlich, Jr., SheriffLIST SOCIAL MEDIA SITES YOU HAVE ACCOUNTS ON:FACEBOOK:TW ITTER :OTHER:YESN OY E SN OA CCOUNT NAM E:WORK / Employment HISTORYPLEASE LIST POSITIONS, STARTING WITH YOUR MOST RECENT Employment AND ENDING WITH YOUR FIRST FULL-TIME, PERMANENT P LO YER / CO M PA NY N AM E:MAILING ADDRESS (Street / Box / City / State / Zip):TELEPHONE:TYPE OF BUSINESS:EM PLOYED FROM:TO:JOB TITLE / POSITION://MONTH / YEARMONTH / YEARSUPERVISOR:SUPERVISOR'S TITLE:BEGINNING ANNUAL SALARY:ENDING ANNUAL SALARY:REASON FOR LEAVING:DUTIES: PLEASE LIST YOUR MAJOR JOB DUTIES AND APPROXIMATE PERCENTAGE OF TIME SPENT ON EACH OF TIMEMAJOR DUTIESAWARDS / COMMENDATIONS: PLEASE LIST ANY AWARDS, COMMENDATIONS, AND / OR PROMOTIONS RECEIVED IN THE PERFORMANCE OF YOUR JOB TITLESDATEDESCRIPTION OF AWARD / COMMENDATION / PROMOTIONPLEASE LIST ANY DISCIPLINARY ACTION TAKEN AGAINST YOU BY THIS EMPLOYER, AND EXPLAIN THE NATURE AND EXTENT OF THEACTION TAKEN.

6 ATTACH SHEET IF NEED MORE of 11 The Plaquemines Parish Sheriff's Office is an Equal Opportunity EmployerWORK / Employment HISTORYPLEASE LIST POSITIONS, STARTING WITH YOUR MOST RECENT Employment AND ENDING WITH YOUR FIRST FULL-TIME, PERMANENT / COMPANY NAME:ADDRESS:KIND OF BUSINESS:TELEPHONE:EM PLOYED FROM:JOB TITLE / POSITION:TO:MONTH / YEARMONTH / YEARSUPERVISOR:SUPERVISOR'S TITLE:BEGINNING ANNUAL SALARY:ENDING ANNUAL SALARY:REASON FOR LEAVING:DUTIES: PLEASE LIST THE MAJOR DUTIES AND GIVE AN APPROXIMATE PERCENTAGE OF TIME SPENT ON EACH OF TIMEMAJOR DUTIESDATEDESCRIPTION OF AWARD I COMMENDATION / PROMOTIONAWARDS / COMMENDATIONS: PLEASE LIST ANY AWARDS, COMMENDATIONS, AND / OR PROMOTIONS RECEIVED IN THE PERFORMANCE OF YOUR JOB TITLESPLEASE LIST ANY DISCIPLINARY ACTION TAKEN AGAINST YOU BY THIS EMPLOYER, AND EXPLAIN THE NATURE AND EXTENT OF THEACTION of 11 The Plaquemines Parish Sheriff's Office is an Equal Opportunity EmployerWORK / Employment HISTORYEMPLOYER / COMPANY NAME:ADDRESS:KIND OF BUSINESS:TELEPHONE:TO:EMPLOYED FROM:JOB TITLE / POSITION:MONTH / YEARMONTH / YEARSUPERVISOR:SUPERVISOR'S TITLE:BEGINNING ANNUAL SALARY:ENDING ANNUAL SALARY:REASON FOR LEAVING.

7 PERCENT OF TIMEMAJOR DUTIESDATEDESCRIPTION OF AWARD / COMMENDATION I PROMOTIONPLEASE LIST POSITIONS, STARTING WITH YOUR MOST RECENT Employment AND ENDING WITH YOUR FIRST FULL-TIME, PERMANENT : PLEASE LIST THE MAJOR DUTIES AND GIVE AN APPROXIMATE PERCENTAGE OF TIME SPENT ON EACH / COMMENDATIONS: PLEASE LIST ANY AWARDS, COMMENDATIONS, AND / OR PROMOTIONS RECEIVED IN THE PERFORMANCE OF YOUR JOB TITLESPLEASE LIST ANY DISCIPLINARY ACTION TAKEN AGAINST YOU BY THIS EMPLOYER, AND EXPLAIN THE NATURE AND EXTENT OF THEACTION of 11 The Plaquemines Parish Sheriff's Office is an Equal Opportunity EmployerLENGTH OF TIME KNOWN:I AM PROFICIENT IN THE USE AND OPERATION OF THE FOLLOWING COMPUTER SOFTWARE:I SPEAK THE FOLLOWING FOREIGN LANGUAGES:I AM PROFICIENT IN THE FOLLOWING AREAS:ARTWORKA U T O M O T I V EACCOUNTINGAVIATIONCOMPUTER SCIENCEBUSINESS MACHINESCOMMUNICATIONS / ELECTRONICSIDENTIFICATIONLEGALCONSTRUCTI ONFIREARMSM AR TIAL ART SM U S I CPHOTOGRAPHYOTHER(S) Please Specify:PLEASE LIST ANY JOB-RELATED ORGANIZATIONS, CLUBS, PROFESSIONAL / AFFILIATIONS, SOCIETIES, OR OTHER ASSOCIATIONS TOWHICH YOU BELONG:MILITARY BACKGROUNDAMICOAST GUARDMARINESAIR FORCEN A V YARMYA VETERAN OF A COMPONENT:AM NOTI SERVED FR O//YEARMONTHMONTHYEARHONORABLEOTHER DISCHARGEDISHONORABLEAND RECEIVED ANIF YOUR DISCHARGE WAS OTHER THAN HONORABLE, PLEASE EXPLAIN.

8 4 Please attach a copy of DD Form 214 and/or NGB22A MMARINESAIR FORCEN A V YARMYA M IL IT ARY R ESER VIST O F T HEICOAST GUARDAM NOTWHAT EXPERIENCE, SPECIAL TRAINING OR EDUCATION, AND SPECIAL RECOGNITION(S) DID YOU RECEIVE WHILE IN THE MILITARY?PERSONAL REFERENCESNO FAMILY MEMBERS OR SHERIFF'S OFFICE EMPLOYEESNAME:TELEPHONE:MAILING ADDRESS: ( street / Box / City / state / Zip )LENGTH OF TIME KNOWN:TELEPHONE:MAILING ADDRESS: ( street / Box / City / state / Zip )NATURE OF RELATIONSHIP:LENGTH OF TIME KNOWN:NAME:TELEPHONE:MAILING ADDRESS: (street / Box / City / state / Zip )6 of 11 SPANISHFRENCHARABICRUSSIANV IET NA M E SEOTHER: SPECIFY:The Plaquemines Parish Sheriff's Office is an Equal Opportunity EmployerNATURE OF RELATIONSHIP:NAME:NATURE OF RELATIONSHIP.

9 MEDICAL AMREGISTERED FOR THE SELECTIVE REGISTERED VOTER OFIAM NOTHAVEHASBEEN REF USED REASO NABLE CONSIDERED SATISFACTORY IN THE PAST & IMY CREDIT HISTORY-HAVE NOTHAS NOTDOHAVE RELIABLE TRANSPORTATION TO NOTI AM AVAILABLETO BEGIN WORK ON:TRAINING AND EDUCATIONNAME, ADDRESS, CITY, STATE, ZIP CODE OF LAST HIGH SCHOOL ATTENDED:DIPLOMAI RECEIVED AIN THE YEAR OF:GEDPROFESSIONAL / BUSINESS /TECHNICAL INSTITUTES & COLLEGES/ UNIVERSITIES ATTENDED AND ATTACH HIGH SCHOOL / GED OF INSTITUTIONAND LOCATIOND A T E S A T T E N D E D(Month / Year)G R A D U A T E(Yes or No)TYPE OF DEGREEEARNEDTITLE OF PROGRAMOR FIELD OF STUDYFrom:/To:/YESN OFrom:/To:/YESN OFrom:/To:/YESNOFrom:/To:/YESNOFrom:/To: YESNOFrom:/To:/YESNOPROFESSIONAL LICENSES / OF LICENSE / CERTIFICATIONDATE ORIGINALLYLICENSED / CERTIFIEDEXPIRATIONDATENAME OF LICENSING / CERTIFYING AUTHORITYEMPLOYMENT WITH THE PLAQUEMINES PARISH SHERIFF'S OFFICE ENTAILS WORKING 8 OR 12 HOUR SHIFTS DEPENDING UPON DIVISION YOU WILL BE ASSIGNED TO.

10 YOU MAY BE WORKING OVERTIME, WORKING ON HOLIDAYS, WEEKENDS AND NIGHTS. FURTHER, HURRICANE DUTY IS .7 of 11IF YOU DO NOT HAVE A HIGH SCHOOL DIPLOMA OR GED, YOUR Application WILL NOT BE Plaquemines Parish Sheriff's Office is an Equal Opportunity EmployerPLEASE EXPLAIN ANY RESTRICTION ON YOUR ABILITY TO WORK THESE HOURS AND SCHEDULES OR NATURAL PLEASE EXPLAIN ANY RESTRICTION ON YOUR ABILITY TO WORK THESE HOURS AND SCHEDULES. FURTHER, DISASTERS; SUCH AS HURRICANES:/DO YOU HAVE ANY VISIBLE TATTOOS? YES NOMISCELLANEOUSTHE INFORMATION PROVIDED IN THIS SECTION WILL NOT NECESSARILY DISQUALIFY YOU FROM BEING CONSIDERED FOR Employment WITH THE PLAQUEMINES PARISH SHERIFF'S OFFICE. FAILURE TO DISCLOSE ALL REQUESTED INFORMATION OR PROVIDING FALSE INFORMATION, HOWEVER, RESULT IN THE IRREVERSIBLE DISQUALIFICATION OF YOUR Application FOR Employment , COMPLETE AND HONEST RESPONSES TO THE FOLLOWING QUESTIONS ARE, THEREFORE, ABSOLUTELY A V ERECEIVED A TRAFFIC VIOLATION(S) DURING THE PAST FIVE (5) NOTIF APPLICABLE, PLEASE LIST THE VIOLATIONS RECEIVED BELOW (ADDITIONAL SPACE FOR VIOLATIONS ON PAGE 11:VIOLATION:CITY / STATE:DATE:VIOLATION:CITY / STATE:DATE:VIOLATION:CITY / STATE:DATE:ARRESTS:H A V EIBEEN ARR NEVERIF APPLICABLE, PLEASE STATE THE YEAR THE ARREST OCCURRED, THE ARRESTING AGENCY, AND EXPLAIN THE SPECIFICS OFTHE ARREST IN THE EXPLANATION STATEMENT ON PAGE 11.)