UNCLASSIFIED EMPLOYMENT APPLICATION

PERSONAL DATA Date:      
Name:        Date of Birth:    
                            First                            Middle                             Last                                                         Month                  Day        Year
Present Address:    Phone: 
                                       Number                 Street                           City                        State            Zip                         Home/Message
Permanent Address:  Phone:
                                           Number                 Street                           City                        State            Zip                          Home/Message
Have you ever worked at Grambling State University or any other Louisiana State Agency?  Yes  No
If Yes, Give Agency and dates:
Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? Yes  No
Optional: In case of emergency notify.
Name: Address:      Phone:
                                                                             Number                Street                  City               State                 Zip    
Position Desired 1. Date you will be available    Full Time    Part Time
2. Salary Desired $              Permanent  Temporary
 
How did you learn about this position?
Newspaper or other media advertisement Employee or Personal Reference
Walk-in Other
Yes  No Have you ever been on probation or sentenced to jail/prison as a result of a felony conviction or guilty plea? If yes, provide nature of offense and date of conviction  . A yes will not necessarily bar you 
from State Employment (click here for our pre-employment screening procedure)
Yes  No Have you ever been fired from a job or resigned to avoid dismissal?
Are you currently holding or running for an elective public office? Yes  No.  If yes, provide office, city, state . Are you currently holding a full-time appointive office
in the government of this state or in the government of a political subdivision thereof? Yes  No.  If yes, provide office,
 city, state .
* an up-to-date resume' may be enclosed herewith for schooling and employment history documentation
Type School City/State From Month Year (MM/YY) To Month Year (MM/YY) Major Course of Study Minor Degree Diploma
High School/GED
College
Graduate School
(Workshops, Institutes)
  
EMPLOYMENT HISTORY		 *Please do not exceed the space provided, attach separate document if necessary.
EMPLOYER   TITLES AND DUTIES
Firm Name Starting Date 
Address: Salary
Ending Date 
Salary
Type of business:
Supervisor Day Telephone



Reason for leaving:
EMPLOYER   TITLES AND DUTIES
Firm Name Starting Date 
Address: Salary
Ending Date 
Salary
Type of business:
Supervisor Day Telephone



Reason for leaving:
EMPLOYER   TITLES AND DUTIES
Firm Name Starting Date 
Address: Salary
Ending Date 
Salary
Type of business:
Supervisor Day Telephone



Reason for leaving:
Optional: Other names under which you have worked at the employers listed above 

Click here for the *required reference check authorization and verification form.

The information provided in this application is true to the best of my knowledge. Grambling State University is authorized to investigate my record with previous employers. I recognize that false statements on this form shall be considered sufficient cause for the rejection of my application or dismissal if I am employed.

I understand that if employed, my appointment will be "at will" meaning that I would not be guaranteed employment for any specified period of time (Exception: Faculty appointments served by contract period).

Date_________________ Year______                        Signature__________________________________
It is the policy of Grambling State University not to discriminate against any applicant, on the basis of race, color, religion, sex, marital status, age, national origin, political affiliation, veteran status or the presence of handicap/disability.

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