State of Arkansas
Employment Application
■Applications for employment with the State of Arkansas, or any subdivision thereof, are accepted without regard to sex, race or color, national origin, handicap/disabiIity, age, religion, or politi- cal affiliation. Conviction of a crime does not automatically bar any applicant from employment or other opportunities with the State of Arkansas.
■Applications, once filed, may be subject to disclosure as a public record under the Arkansas Freedom of Information Act.
■Applications filed do not create a contract of employment with the State of Arkansas or any of its subdivisions. If any individual is hired, employment is not for any definite period of time. Individuals hired will also be required to provide proof of eligibil- ity to work in the United States pursuant to the Immigration Reform and Control Act of 1986.
■Qualified applicants with disabilities, as defined in the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, may request any needed accommodations to par- ticipate in the application process.
EQUAL EMPLOYMENT DATA This section is designed to collect information which will be
used in the completion of various state and federal reports and will not be used in the processing of, or remain part of, your application. The completion of this section is voluntary.
Applicant's Name ______________________________________________________
Social Security Number________________________
Date of Birth___________________ |
❑ Male |
❑ Female |
■Check one of the four (4) listed which you consider yourself to be:
❑White (Descendant of the original peoples of Europe, North Africa, or the Middle East)
❑Black (Descendant of the black racial groups in Africa)
❑American Indian or Alaskan Native (Descendant of any of the original peoples of North
America, and who maintains cultural identification through tribal affiliation or community recognition)
❑Asian or Pacific Islander (Descendant of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands)
Do you consider yourself to be- Hispanic (A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish Culture origin, regardless of race)? ❑ Yes ❑ No
■Military History
If you believe you may be eligible for veterans preference consideration, complete this section. The Arkansas Veterans Preference Act states specific requirements which must be met in order to be eligible for veterans preference. Under certain conditions spouses, widows, or widowers of qualified veterans may also be eligible for veterans preference. For considera- tion of veterans preference, proof such as a DD-214, current letter from the Veterans Administration, or other official documentation may be required. Specific questions regarding veterans preference should be addressed to individual state agency personnel offices.
Have you served on active duty in the United States military, excluding Active Duty for Training (AcDuTra) and Reserve Military Annual Training (AT)?❑ Yes ❑ No
Branch of service________________________________________________________
Date of entry ___________________________________________________________
Date of discharge _______________________________________________________
Type of discharge _______________________________________________________
■How did you learn of this job opening?
❑Newspaper
❑Employment Security Department
❑Agency announcement
❑Educational Institution. Name of Institution:_________________________________
❑Other Explain: _______________________________________________________
APPLICATION FOR EMPLOYMENT
Please answer all questions which apply to you. If they do not apply, mark them N/A. Please print, type or write legibly.
LASTNAME |
FIRSTNAME |
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MIDDLE NAME |
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COMPLETE MAILINGADDRESS |
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MESSAGEOROTHERPHONENUMBER
Position(s) for which you are applying (give title(s) and position number(s) if known):
1._______________________________________________________________________
2._______________________________________________________________________
3._______________________________________________________________________
4._______________________________________________________________________
EMPLOYMENT STATUS SECTION
Will you accept employment anywhere in the State? . . . . . . . . . . . . . ❑ Yes❑ No
If no, where would you accept employment?____________________________________________________
Will you accept any type of employment? |
❑ Yes |
❑ No |
If no, check which type(s) of employment you will accept. ❑ Full Employment |
❑ Part Time ❑ Temporary |
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Have you ever filed an application for employment with this agency? . ❑ Yes |
❑ No |
If yes, what was your name at that time? ______________________________________________________
Have you ever been employed by Arkansas State Government? . . . . ❑ Yes❑ No
List professional license(s) relevant to position(s) for which you are applying. Give type of license, license number, date of expiration, and state. _________________________________________________________
_______________________________________________________________________________________
May we contact your current employer? |
❑ Yes |
❑ No |
May we contact your former employer(s)? |
❑ Yes |
❑ No |
EDUCATIONAL HISTORY
Received:
❑ Diploma ❑ GED ❑ Certificate: Type Awarded:________________
If None, Highest Grade Completed _____
■List below post secondary schools, colleges, universities, trade/vocational, or other attended:
NOTE: For hours completed indicate whether semester hours, quarter hours, clock hours, etc.
Hours
Completed
(see note below)
WORK HISTORY
List all prior work experience, including military service, beginning with your most recent employment (include all work experience even if you do not believe that experience to be related to the position or positions for which you are applying). You may include vol- unteer or unpaid work as part of your history; however, you should include the number of hours per week which you performed these duties. If you do not have enough space to list all your work experience, use a separate sheet for continuation. If you wish to include a resume instead of completing the work history section, make sure all the requested information is included.
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Reason for leaving
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Employer |
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per week __________ |
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Your job duties (be specific) |
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Employer |
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Complete mailing address |
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To _______________ |
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Supervisor’s name |
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per week __________ |
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Name under which employed |
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Your job duties (be specific) |
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SPECIAL SKILLS
Typing Speed (corrected words per minute):
Stenographic Speed (words per minute):
Can you transcribe machine dictation? ❑ Yes ❑ No
List the business machines, computers and word processors you can operate:
List any other skills relative to the job(s) for which you are applying:
REFERENCES
■Please list three (3) persons not related to you, who have knowledge of your work qualifications, are not previous or current employer(s), and can serve as a reference for you.
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
NEPOTISM
■Do you have any relatives employed by the state agency to which you are submitting this application for employ- ment?❑ Yes ❑ No If yes, complete the remainder of this section. (This question is being asked for the sole purpose of ensuring compliance with any applicable law or policy concerning nepotism.)
Name |
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Agency employed by: |
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Before you sign this application
Check over your answers to make sure that all questions have been completed properly. If the job you are applying for requires a college degree or certification, a copy of your transcript, certificate, or license may be required as a condition of employment.
I, the below signed individual, hereby declare that, to the best of knowledge and my ability, the information on this application is true and factual.
I understand that if I am hired, that my employment is not for any definite period of time, and I may be terminated at any time.
I understand that if I state I have a college degree, and do not have one, that my application will be rejected or, if hired, I will be terminated in accordance with Arkansas Code 21-12-102.
I understand that my application may be subject to disclosure as a public record under the Arkansas Freedom of Information Act. I understand that certain jobs may require an acceptable driver’s safety record, and that if my current or future driver’s record is unacceptable under the State Driver’s Risk Program, my application may be rejected and, if hired, I may be subject to termination. I understand that I will be required to provide proof of eligibility to work in the United States pursuant to the immigration Reform
and Control Act of 1986 as a condition of my employment.
I understand that false, misleading, or incomplete statements could lead to my dismissal as an employee or rejection as an appli- cant.
I also understand that some jobs require background checks, security clearance, or compliance with other specific agency hir- ing policies prior to my employment, or as a condition of employment; and that failure to meet those requirements may lead to my rejection as an applicant for, or termination from, that job.
I affirm that it is my genuine intent to seek, and if offered, employment in Arkansas State Government, and this application is sub- mitted solely for that purpose and for no other purposes.
___________________________________________________________ |
____________________________________ |
Signature of applicant |
Date of signature |
State of Arkansas
Statement of Selective Service Status
I understand that to be eligible for employment with the State of Arkansas I must register, or be exempt from registration, with the Selective Service System in accordance with the Military Selective Act, 50 USC Appx §452 et seq., as specified in Act 228 of the 1997 Acts of the Arkansas General Assembly.
OI swear or affirm under penalty of perjury that I have registered with the Selective Service System.
OI swear or affirm under penalty of perjury that I am exempt from registration because of the following provision(s) of the Military Selective Service Act or Act 228 of the 1997 Acts of the Arkansas General Assembly:
OI am female.
OI am under 18 years of age.
OI am 26 years of age or over.
OI am currently a member of the armed forces on active duty.
OI am an exempted resident alien.
OOther: Specify:
Name (Please Print):
Signature:Date:
Social Security Number:
(Member Name)
STATE OF ARKANSAS
Department of Finance and Administration
EMPLOYEE DISCLOSURE/CERTIFICATION AND EMPLOYMENT OF FAMILY MEMBERS FORM
Answer the following questions regarding your current, former* and future employment with the State of Arkansas:
1. |
Are you a current state employee? |
Yes |
2. |
Are you a former state employee? |
Yes |
3.Are you a current member of the Arkansas General Assembly (House or Senate)
or a current Constitutional Officer**? |
Yes |
4.Are you the spouse of a current member of the Arkansas General Assembly or spouse of a current
Constitutional Officer? _________________________________(Member/Officer Name) |
Yes |
► If “Yes”, is your expected salary above the pay grade 13, level IV? |
Yes |
5.Are you a former member or the spouse of a former member ________________ (Member Name)
of the Arkansas General Assembly (House or Senate)? |
Yes |
► If “Yes,” did you serve or did your spouse serve within the last 24 months? |
Yes |
►If “Yes,” during the previous 24 months prior to your leaving office or your spouse leaving |
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office, was the position for which you are being considered created by legislative action, or if |
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the maximum salary level increased by more than 15%, was it authorized by legislative action? |
YES |
6.Are you an immediate family member*** (other than the spouse) of a member of the Arkansas General
Assembly or a Constitutional Officer? |
YES |
►If “Yes”, ______________________________________________________(Member/Officer Name)
F-3
No
No
No
No
No
No
No
NO
NO
7.Are you an immediate family member of a state employee, state board, or Commission member?
► IF “YES”, ___________________________________________________________
8.Are you a relative of the supervisor or hiring official, or will this position have supervisory responsibility over a relative disclosed above?
a)If “Yes”, are you a spouse of a member of the Arkansas General Assembly or a Constitutional
Officer? _____________________________________________________(Member/Officer Name)
OR
b)If “Yes”, are you an immediate family member (other than the spouse) of a member of the Arkansas General Assembly, a Constitutional Officer, a state employee, or board or commission member?
►If “Yes”, what is the relationship and name?_______________________________________
*Former is defined as within the last 24 months.
**Constitutional Officer: Governor, Lt. Governor, Secretary of State, Attorney General, Auditor, Treasurer, Land Commissioner.
***Immediate family member includes: spouse, mother, father, sister, brother, child, mother-in-law, father-in-law, sister-in-law, brother-in-law, daughter-in law, and son-in-law.
I understand that to be eligible for employment with the State of Arkansas, I must be in compliance with Governor’s Executive Order 98-04, Governor’s Policy Directive No. 8 and Arkansas Code Annotated §21-8-304, which state, in part, that, while employed as a state employee, I cannot enter into any Professional Services Contract or Consultant Service Contract with any state agency unless I am providing Nursing Services and contracting with the Department of Human Services. I assert that I have answered the above questions to the best of my knowledge, and I understand that failure to disclose this information may result in disciplinary action, if I am hired by this agency.
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Signature of Applicant |
Social Security Number |
Date |
INSTRUCTIONS FOR HIRING OFFICIAL:
A.Regardless of the answer in #1 or #2, complete this form. Submit this form with the hire packet.
B.If applicant marked #3 “Yes”, this person cannot be hired.
C.If applicant marked all items in #4 “Yes”, complete this form and submit to Chief Fiscal Officer (CFO) and Joint Budget Committee (JBC) / Legislative Council (LC) for approval. Submit approved form with hire packet.
D.If applicant marked all items in #5 “Yes”, this person cannot be hired.
E.If applicant marked #6, #7 or #8b “Yes”, complete this form and submit to agency director. Submit approved form with hire packet.
F.If applicant marked #8a “Yes”, complete this form and submit to CFO and JBC/LC for approval. Submit approved form with hire packet.
G.If applicant marked any item in #3, #4, #5, #6, #7, #8a or #8b “No”, no further action is needed. Submit this form with the hire packet.
Agency/Institution |
Cossatot Community College-UA |
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Hiring Official |
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Position Applied for |
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Salary |
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I certify that the applicant meets the education and experience qualifications required to perform the duties of the position for which they are being considered.
_____________________________________________________ |
870-584-4471 |
Signature of Agency/Institution Hiring Official |
Phone Number |
677
Agency/Institution Director or Designee |
Agency Number |
Date |
F-5
STATE OF ARKANSAS
Department of Finance and Administration
Employee Disclosure Requirements Notice
Employees must report any benefit obtained from a state contract by a business in which the employee has a financial interest. Ark. Code Ann. § 19-11-706. The employee must report this benefit to the Director of the Department of Finance and Administration.
A state employee has a “financial interest” in a business if he/she:
•has received within the past year, or is presently or in the future entitled to receive, more than one thousand dollars ($1000) per year, as a result of ownership of any part of the business or any involvement in the business; or
•owns more than a five percent (5%) interest in the business; or
•holds a position in the business such as an officer, director, trustee, partner, employee, or the like, or holds any position of management.
Any employee who knows or should have known of such benefit and fails to report the benefit to the director is in breach of the ethical standards of Ark. Code Ann. § 19-11-706.
Employee Disclosure Restriction Notice
State employees are restricted from employment under certain conditions, both during the time they are employed by the state and after they leave state employment. Ark. Code Ann. § 19-11-709. These restrictions include:
•employment of a current state employee involved in procurement by any party contracting with the state;
•former employees from representing anyone other than the state under certain conditions in matters which the employee participated personally and substantially or which were within the former employee’s official responsibility;
•partners of a current or former state employee from representing anyone other than the state under certain conditions; and
•selling to the state after termination of employment under certain conditions.
Any current or former state employee who violates any of these employment restrictions is in breach of the ethical standards of Ark. Code Ann. § 19-11-709.
Penalties for Non-Compliance with Ark. Code Ann. § 19-11-706 or § 19-11-709
In addition to civil and administrative remedies, Ark. Code Ann. § 19-11-712 allows the Director of the Department of Finance and Administration to impose, against any employee who fails to comply with Ark. Code Ann. § 19-11-706 or § 19-11-709, after notice and an opportunity for a hearing, any one or more of the following:
•oral or written warnings or reprimands;
•forfeiture of pay without suspension;
•suspension with or without pay for specified periods of time; and
•termination of employment.
Pursuant to Arkansas Code Annotated § 19-11-702, any employee who shall knowingly violate either of these restrictions shall be guilty of a felony and upon conviction shall be fined in any sum not to exceed ten thousand dollars ($10,000) or shall be imprisoned not less than one (1) nor more than five (5) years, or shall be punished by both.
I certify that I have read this Notice and the Ark. Code Ann. §§ 19-11-706, 19-11-702, 19-11-709 and 19-11-712 on the reverse side. The Regulations promulgated to enforce Executive Order 98-04 contain additional information regarding this reporting requirement at Section 13 & 14, posted by the agency in a conspicuous place. I understand that it is my responsibility to comply with the requirement to report as explained in Ark. Code Ann §§ 19-11-706 & 19-11-709, this Notice and the regulation.
Cossatot Community College of the University of Arkansas
Agency Name
Name of Employee (Please Print)Social Security Number
Signature of Employee |
Date |
See back for Arkansas Code Annotated §§ 19-11-702, 19-11-706, 19-11-709 and 19-11-712
EXCERPTS FROM ARKANSAS CODE ANNOTATED §19-11
SUBCHAPTER 7
19-11-702. Penalties.
Any employee or nonemployee who shall knowingly violate any of the provisions of this subchapter shall be guilty of a felony and upon conviction shall be fined in any sum not to exceed ten thousand dollars ($10,000) or shall be imprisoned not less than one (1) nor more than five (5) years, or shall be punished by both.
19-11-706. Employee disclosure requirements.
(a)Disclosure of Benefit Received from Contract. Any employee who has or obtains any benefit from any state contract with a
business in which the employee has a financial interest shall report such benefit to the Director of the Department of Finance and Administration. However, this section shall not apply to a contract with a business where the employee's interest in the business has been placed in a disclosed blind trust.
(b)Failure to Disclose Benefit Received. Any employee who knows or should have known of such benefit and fails to report the
benefit to the director is in breach of the ethical standards of this section.
19-11-709. Restrictions on employment of present and former employees.
(a)Contemporaneous Employment Prohibited. It shall be a breach of ethical standards for any employee who is involved in procurement to become or be, while such an employee, the employee of any party contracting with the state agency by which the employee is employed.
(b)Restrictions on Former Employees in Matters Connected with Their Former Duties.
(1)Permanent Disqualification of Former Employee Personally Involved in a Particular Matter. It shall be a breach of ethical standards for any former employee knowingly to act as a principal or as an agent for anyone other than the state in connection with any:
(A)Judicial or other proceeding, application, request for a ruling, or other determination;
(B)Contract;
(C)Claim; or
(D)Charge or controversy
in which the employee participated personally and substantially through decision, approval, disapproval, recommendation, rendering of advice, investigation, or otherwise while an employee, where the state is a party or has a direct and substantial interest.
(2)One-Year Representation Restriction Regarding Matters for Which a Former Employee Was Officially Responsible. It shall be a breach of ethical standards for any former employee, within one (1) year after cessation of the former employee's official responsibility in connection with any:
(A)Judicial or other proceeding, application, request for a ruling, or other determination;
(B)Contract;
(C)Claim; or
(D)Charge or controversy knowingly to act as a principal or as an agent for anyone other than the state in matters which were within the former employee'sofficial responsibility, where the state is a
party or has a direct or substantial interest.
(c)Disqualification of Partners.
(1)When Partner Is a State Employee. It shall be a breach of ethical standards for a person who is a partner of an employee
knowingly to act as a principal or as an agent for anyone other than the state in connection with any:
(A)Judicial or other proceeding, application, request for a ruling, or other determination; Contract;
(B)Claim; or
(C)Charge or controversy in which the employee either participates personally and substantially through decision, approval, disapproval, recommendation, the rendering of advice, investigation, or otherwise, or which is the subject of the employee's official responsibility, here the state is a party or has a direct and substantial interest.
(2)When a Partner Is a Former State Employee. It shall be a
breach of ethical standards for a partner of a former employee knowingly to act as a principal or as an agent for anyone other than the state where such former employee is barred under subsection (b) of this section.
(d)(1) Selling to State After Termination of Employment Is Prohibited. It shall be a breach of ethical standards for any former employee, unless the former employee's last annual salary did not exceed ten thousand five hundred dollars ($10,500), to engage in selling or attempting to sell commodities or services to the state for one (1) year following the date employment ceased.
(2) The term "sell", as used in this subsection, means signing a bid, proposal, or contract; negotiating a contract; contacting any employee for the purpose of obtaining, negotiating, or discussing changes in specifications, price, cost allowances, or other terms of a contract; settling disputes concerning performance of a contract; or any other liaison activity with a view toward the ultimate consummation of a sale although the actual contract therefor is subsequently negotiated by another person.
(e)(1) This section is not intended to preclude a former employee from accepting employment with private industry solely because his employer is a contractor with this state.
(2)This section is not intended to preclude an employee, a former employee, or a partner of an employee or former employee from filing an action as a taxpayer for alleged violations of this subchapter.
19-11-712. Civil and administrative remedies against employees who breach ethical standards.
(a)Existing Remedies Not Impaired. Civil and administrative remedies against employees which are in existence on July 1,1979, shall not be impaired.
(b)Supplemental Remedies. In addition to existing remedies for breach of the ethical standards of this subchapter, or regulations promulgated thereunder, the Director of the Department of Finance and Administration may impose any one (1) or more of the following:
(1)Oral or written warnings or reprimands;
(2)Forfeiture of pay without suspension;
(3)Suspension with or without pay for specified periods of time; &
(4)Termination of employment.
(c)Right to Recover from Employee Value Received in Breach of Ethical Standards. The value of anything received by an employee in breach of the ethical standards of this subchapter, or regulations promulgated thereunder, shall be recoverable by the state as provided in § 19-11-714, which refers to recovery of value transferred or received in breach of ethical standards.
(d)Due Process. Notice and an opportunity for a hearing shall be provided prior to imposition of any of the remedies set forth in subsection (b) of this section.
RETURN APPLICATION TO
COSSATOT COMMUNITY COLLEGE
OF THE
UNIVERSITY OF ARKANSAS HUMAN RESOURCE OFFICE P.O. BOX 960
183 HIGHWAY 399
DE QUEEN, AR 71832
Telephone: 870-584-4471, Extension 102
Fax: 870-642-8505
