BLACK RIVER TECHNICAL COLLEGE
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/disability, age, religion, or political 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 eligibility 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 participate 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
y
ou consider
y
ourself to be:
White (Descendant of the original peoples of Europe, North Africa, or the Middle East)
Black (Descendent 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
Militar
y
Histor
y
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 consideration 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 Unites 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
y
ou learn of this
j
ob openin
g
?
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 then N/A. Please print, type or write legibly.
Last Name First Name Middle Name
Complete Mailing Address City State Zip County
Home Phone Number Work Phone Number Message or Other Phone Number
Position(s) for which
y
ou are appl
y
in
g
(
g
ive 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
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
HIGH Received: Certificate If None, Highest Grade
SCHOOL Diploma G.E.D. Type Awarded: Completed:
List below post secondary schools, colleges, universities, trade/vocational, or others attended:
Name and Location
From To
Major/Minor
Hours
Completed
(See note
below)
Degree/
Diploma
Awarded
Date
Graduated
Mo. Yr. Mo. Yr.
Note: For hours completed indicate whether semester hours, quarter hours, clock hours, etc.
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 for which you are applying.)
You may include volunteer 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.
1. Current or most recent employer Business phone number Employment dates
From
Complete mailing address City State Zip Code Month Year
To
Type of business Month Year
Supervisor's name Average hours worked
Name under which employed: Your job title: Per week
Salary
Your job duties (be specific)
Lowest Highest
Reason for leaving
2. Employer Business phone number Employment dates
From
Complete mailing address City State Zip Code Month Year
To
Type of business Month Year
Supervisor's name Average hours worked
Name under which employed: Your job title: Per week
Salary
Your job duties (be specific)
Lowest Highest
Reason for leaving
3. Employer Business phone number Employment dates
From
Complete mailing address City State Zip Code Month Year
To
Type of business Month Year
Supervisor's name Average hours worked
Name under which employed: Your job title: Per week
Salary
Your job duties (be specific)
Lowest Highest
Reason for leaving
4. Employer Business phone number Employment dates
From
Complete mailing address City State Zip Code Month Year
To
Type of business Month Year
Supervisor's name Average hours worked
Name under which employed: Your job title: Per week
Salary
Your job duties (be specific)
Lowest Highest
Reason for leaving
5. Employer Business phone number Employment dates
From
Complete mailing address City State Zip Code Month Year
To
Type of business Month Year
Supervisor's name Average hours worked
Name under which employed: Your job title: Per week
Salary
Your job duties (be specific)
Lowest Highest
Reason for leaving
6. Employer Business phone number Employment dates
From
Complete mailing address City State Zip Code Month Year
To
Type of business Month Year
Supervisor's name Average hours worked
Name under which employed: Your job title: Per week
Salary
Your job duties (be specific)
Lowest Highest
Reason for leaving
SPECIAL SKILLS
Typing Speed (corrected words per minute):
Stenographic Speed (words per minute):
Can you transcribe machine dictation? Yes No
List the business machines,c omputer's 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
employment? 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 my 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 that 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 of 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 any employment.
I understand that false, misleading, or incomplete statements could lead to my dismissal as an employee or rejection as
an applicant.
I also understand that some jobs require special background checks, security clearance, or compliance with other specific
agency hiring policies prior to my employment, or as a condition of employment; and that failure to meet these 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 submitted soley for that purpose and for no other purposes.
Signature of applicant Date of Signature
Reset Form
Print
THE FOLLOWING IS A PAGE FROM A SAMPLE EMPLOYMENT
APPLICATION THAT CONTAINS THE CHECKLIST FOR EMPLOYEE DISCLOSURE.
DISCLOSURE REQUIREMENTS
Governor’s Executive Order 98-04, Governor’s Policy Directive #8, and ACA §21-8-304 require that the following information be disclosed
to be considered for employment with the State of Arkansas.
1. Are you one of the following:
current member of the AR General Assembly? former member of the AR General Assembly?
current constitutional officer? former constitutional officer?
current state employee? former state employee?
2. Are any of your relatives one of the following: (Relative is defined as husband, wife, mother, father, stepmother, stepfather,
mother-in-law, father-in-law, brother, sister, stepbrother, stepsister, half-brother, half-sister, brother-in-law, sister-in-law,
daughter, son, stepdaughter, stepson, daughter-in-law, son-in-law, uncle, aunt, first cousin, nephew, or niece)
current member of the AR General Assembly? former member of the AR General Assembly?
current constitutional officer? former constitutional officer?
current state employee? former state employee?
3. None of the above applies.
4. Certain family or business relationships may prohibit an agency from hiring you. If any block is checked in #1 or #2 above, you
will be required to disclose additional information if you are selected for interview to determine whether your employment
would be prohibited or would require approval. I understand, should I become an employee of the State of Arkansas, that I
may be reprimanded or terminated for failing to disclose the required information or disclosing incorrect information.
I understand that, should I become an employee of the State of Arkansas, I will be required to disclose any benefit obtained from a
state contract by a business in which I have a financial interest, pursuant to ACA §19-11-706, and will be subject to civil, criminal,
and/or administrative remedies if I fail to report such benefits.
I understand that, should I become an employee of the State of Arkansas, I will be restricted both during and after state employment
from certain activities concerning procurement and selling to the state, pursuant to ACA §19-11-709, and will be subject to civil,
criminal, and/or administrative remedies if I violate any of these restrictions.
I also understand that as an employee of the State of Arkansas I am restricted from supervising or being supervised by a relative. If I
am hired and it can be proven that I falsely disclosed information in gaining employment that I could be subject to criminal or civil
penalties under ACA § 25-16-1004 or § 25-16-1005.
Applicant/Employee Name:___________________________________________ Date: ________________________
(Please Print)
Applicant/Employee Signature ____________________________________________________________________________
F-8
Rev. 02/03/15
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