State of Louisiana
John Bel Edwards
GOVERNOR
Rebekah E. Gee MD, MPH
SECRETARY
State of Louisiana
Department of Health and Hospitals
Office of Public Health
EDUCATION AND EXPERIENCE
(Please PRINT Clearly or Type and Fill in COMPLETELY)
Full Name: ____________________________________________________________________________________
Last
First
Middle
Operator ID# or Social Security#: _______________________________ Email: _____________________________
Mailing Address: _______________________________________________________________________________
Number Street
City
State
ZIP
Phone: _____________________________________ Fax: ______________________________________
Did you receive a high school diploma? YES ( ) NO ( ) If not, did you receive an equivalent certificate (GED)? YES ( ) NO ( )
Name and address of high school: __________________________________________________________________________________ ___________________________________________________________________________________
Month/year diploma or GED: ______________________________________________________________________________________
College or University (include name & location of college, dates attended (from-to), credit hours (semester and/or quarter) and note degrees received: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
NOTE: You must provide a copy of your degree and/or your transcipts. Other schools attended (include business, trade, military, etc.). Be sure to include name and address of each school, dates attended (month and year), type of course, and provide copies of diploma or certificates received and DD214. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
Note: if more space is needed, use a separate sheet of paper.
Bienville Building P.O. Box 4489 Bin # 10 Box # 6 Baton Rouge, Louisiana 70821-4489 Phone #: 225/342-7508 Fax #: 225/342-7494
"An Equal Opportunity Employer" Rev10
WATER AND/OR WASTEWATER EXPERIENCE:
CURRENT JOB: Date of employment (include month, day, and year) _________ /______ / __________ to PRESENT
System/Facility Name _________________________________________________________________________________________________ Position Title_____________________________________________________________________________Supervisory Position? Yes ? No Name immediate supervisor ____________________________________________________________________________________________ Describe your water &/or wastewater work in detail: ________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
PREVIOUS Position/Employment: Date of employment (include month, day, & year) _____ /___ / _____ to ______ /___ / ______
System/Facility Name _________________________________________________________________________________________________ Position Title_____________________________________________________________________________Supervisory Position? Yes ? No Name immediate supervisor ____________________________________________________________________________________________ Describe your water &/or wastewater work in detail: ________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
PREVIOUS Position/Employment: Date of employment (include month, day, & year) _____ /___ / _____ to ______ /___ / ______
System/Facility Name _________________________________________________________________________________________________ Position Title_____________________________________________________________________________Supervisory Position? Yes ? No Name immediate supervisor ____________________________________________________________________________________________ Describe your water &/or wastewater work in detail: ________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
PREVIOUS Position/Employment: Date of employment (include month, day, & year) _____ /___ / _____ to ______ /___ / ______
System/Facility Name _________________________________________________________________________________________________ Position Title_____________________________________________________________________________Supervisory Position? Yes ? No Name immediate supervisor ____________________________________________________________________________________________ Describe your water &/or wastewater work in detail: ________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
Note: If more space is needed, use a separate sheet of paper of the same size as this application.
I certify that the above information is true and correct to the best of my knowledge. I understand that any false or erroneous information may be cause for loss of certification.
__________________________________ Date
__________________________________ Date _____________ Previous Credited Points
_________________________________________________ Signature of Operator
_________________________________________________ Signature Of Operator's Supervisor
_____________
Updated Points
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