Louisiana Employment Application
EMPLOYMENT APPLICATION
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
FULL SSN
*
Do you possess a valid Driver's License?
*
Yes
No
Please upload an image of your DL or ID
*
Browse Files
Drag and drop files here
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*Can you, after employment, submit proof of your legal right to work in the United States? (Please check one)
*
Yes
No
Are you at least 18 years old?
*
Yes
No
The State of Louisiana requests the information below so we may comply with federal Equal EmploymentOpportunity law requirements. The information is strictly voluntary and in no way influences employmentprospects
Gender
*
Male
Female
Decline to state
Ethnicity
*
Hispanic or Latino
Non-Hispanic or Non-Latino
Decline to state
Race
*
White Caucasian
Asian
American Indian or Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
2 or more races
Decline to state
Date of Birth
*
-
Month
-
Day
Year
Date
Are you an Army Pays participant?
*
Yes
No
* Are you claiming Veteran’s Preference points on this application?
Yes
No
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Name
*
First Name
Last Name
Middle Initial
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FULL SOCIAL
*
Date of Birth
*
-
Month
-
Day
Year
Date
Check one of the following boxes to attest to your citizenship or immigration status:
*
A citizen of the United States
A noncitizen national of the United States
A lawful permanent resident (Enter USCIS or A-Number.)
authorized to work until
I am aware that federal lawprovides for imprisonment and/orfines for false statements, or theuse of false documents, inconnection with the completion ofthis form. I attest, under penaltyof perjury, that this information,including my selection of the boxattesting to my citizenship orimmigration status, is true and correct
*
Today's date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Filing Status
*
Single or Married filing separately
Married filing separately or qualifying serving spouse
Head of Household
Type a Multiply the number of qualifying children under 17 by $2,000
*
Multiply the number of other dependents
*
Add total amounts from above
Signature
Date
-
Month
-
Day
Year
Date
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