Arkansas Employment Application Form – Fill Out and Use This PDF

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: _______________________________________________________

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.

Name

Address

Telephone

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	Relation	Agency employed by:

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:

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

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