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Revised 02/22/2012
National Park College
Department of Human Resources
EMPLOYEE HIRE INFORMATION
NPC ID: ______________________________
Last Name: ____________________________ First Name: _______________________ M/I ______
Cell Phone: _________________________________Home Phone: __________________________
E-mail:____________________________________________________________________________
Home Address: _____________________________________________________________________
City: _____________________________________________ State: __________ ZIP: _________
Birth Date: ________________ Sex: F M Social Security# ___________________________
Hire Date: _____________Home Dept: _________________________________________________
Supervisor: _______________________________ Position: _________________________________
Race/Ethnicity: Choose one of the following:
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
White
Native Hawaiian or Other Pacific Islander
Nonresident alien
Ethnicity unknown
Current NPC Student: Yes No
If yes, total hours currently enrolled _______
Highest Degree Level:
High School or Equivalent
Technical Certification
Two-year Associates Degree
Bachelor’s Degree
Master’s Degree
Doctorate
Concurrent Employment:
Are you presently employed with another state facility? No Yes
If yes, where? ______________________________________________________________________
Do you have Prior Service with a state agency? No Yes
Are you a current member of Arkansas Teacher’s Retirement Service (ATRS)? No Yes
Are you a current member of Arkansas Public Employee Retirement System (APERS)?
No Yes
How did you learn of this position?
NPC website
NPC Employee
Newspaper
Other ____________________
Are you a veteran? Yes No
If yes, type of discharge:
Honorable Dishonorable
I am currently active duty
Military.
National Park College
Department of Human Resources
STATEMENT OF SELECTIVE SERVICE STATUS
IN COMPLIANCE WITH ACT 228 OF THE 1997 ACTS OF
THE
ARKANSAS GENERAL ASSEMBLY
I understand that to be eligible for employment with the State of
Arkansas or eligible for admission to an institution of higher
education, I must register, or be exempt from registration, with
the Selective Service System in accordance with the Military
Selective Service Act, 50 U.S.C. Appx § 451 et seq., as specified in
Act 228 of the 197 Acts of the Arkansas General Assembly. I
therefore swear or affirm under penalty of perjury that I have
registered with the Selective Service System, or I am exempted
from such 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:
□ I am female,
□ I am a current member of the armed forces on active
duty,
□ I am under 18 years of age,
□ I am 26 years of age or over,
□ I am an exempted resident alien,
□ Other (specify below).
Name (Please Print)
Signature
Date
click to sign
signature
click to edit
National Park College
Authorization Agreement for Direct Deposits
I, _______________________________ do hereby authorize the above named company, hereinafter
(Print Name)
referred to as the Originator, to initiate credit entries to the account indicated below, and to initiate
corrective reversal entries (debits) to the account indicated below in the event any credit entries are
originated in error.
Name on the Account
Name of Depository
Financial Institution
Location of Depository Financial Institution:
City: State Zip Phone
Routing Number ___ ___ ___ ___ ___ ___ ___ ___ ___ (nine digits on left side of check)
Account Number (middle number, before check #)
Checking _______% of Net Pay or Set Dollar Amount _________________________________
Savings _______% of Net Pay or Set Dollar Amount ___________________________________
This authority is to remain in effect until the Originator has received my/our written notification of its
termination in such time and in such manner as to afford the Originator a reasonable opportunity to act
upon it.
NPC ID SSN
Signed Date
AFFIX VOIDED CHECK OR BANK ORIGINATED INFORMATION BELOW
Deposit Slips are not acceptable.
(Return Completed Authorization to the Payroll Office.)
STATE OF ARKANSAS
Department of Finance and Administration
EMPLOYEE DISCLOSURE/CERTIFICATION AND EMPLOYMENT OF FAMILY MEMBERS FORM
I understand to be eligible for employment with the State of Arkansas, I must comply with Governor’s Executive Order 98-04, ACA §21-1-401-408, and
ACA §25-16-1001-1007. I also understand that as an employee of the State of Arkansas I am restricted from supervising or being supervised by a
relative specifically under ACA §25-16-1002. If I am hired and it can be proven I falsely disclosed or failed to disclose information I could be subject to
criminal, civil and/or administrative remedies. I assert that I have answered the above questions to the best of my knowledge.
F-3/F-4 Rev. 06/27/12
Are you a current state employee
A
?
Are you a former
B
state employee
A
?
Are you a current Constitutional Officer
C
?
If “Yes”, were you employed prior to your election into office?
3b.
► If “Yes,” give
date elected
Are you the spouse of a current Constitutional Officer
C
?
4a.
► If “Yes,” give
spouse’s name
position/office
If “Yes”, is your expected salary above $37,649?
Are you the spouse of a former
B
Constitutional Officer
C
?
5.a
► If “Yes,” give
spouse’s name
position/office
Are you or your spouse a former
B
General Assembly member
D
?
6a.
► If “Yes,” give
spouse’s name
position/office
If “Yes”, within the 24 months prior to your leaving office or your spouse leaving office, was the position for
which you are being considered created by legislative action, or if the maximum salary level increased by
more than 15%, was this authorized by legislative action?
Are you a relative
E
of the Public Official
F
in charge of the agency
G
in which you are applying?
7a.
► If “Yes,” give
relative’s
E
name
position/office
relationship
Are you a relative
E
of a state employee
A
, state board or commission member or are you a relative
E
(other
than the spouse) of a Constitutional Officer
C
or an Arkansas General Assembly member
D
?
8a.
► If “Yes,” give
relative’s
E
name
position/office
relationship
If you checked “Yes” in #8 above, does this relative
E
work within the state agency
G
in which you are
applying?
If “Yes”, is the position for which you are applying in the direct line of supervision of your relative
E
or will the
position be a supervisory employee of the relative
E
.
-
-
Applicant Name (Please Print)
Signature of Applicant
Date
Social Security Number
This form is to be completed by all interviewed applicants for a position.
Definitions for the symbols in questions 1 – 9 below. Please read before continuing.
A State Employee any employee of any state agency employed in a regular salary position or extra-help position not to include contract labor.
B Former is defined as within the last 24 months.
C Constitutional Officer: Governor, Lt. Governor, Secretary of State, Attorney General, Auditor, Treasurer, Land Commissioner, General Assembly
member.
D General Assembly member: member of the Arkansas Senate or the Arkansas House of Representatives.
E Relative includes: husband, wife, mother, father, stepmother, stepfather, mother-in-law, father-in-law, sister, brother, stepsister, stepbrother, half-
sister, half-brother, sister-in-law, brother-in-law, daughter, son, stepdaughter, stepson, daughter-in-law, son-in-law, aunt, uncle, first cousin, niece
or nephew.
F Public Official: constitutional officers; members of the Arkansas General Assembly; the executive head of any agency, department, board,
commission, institution, bureau, or council of the state.
G Agency or State Agency: every agency, board, commission, department, division, institution, and other office of state government located within
the executive branch of government and under the control of the Governor.
click to sign
signature
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STATE OF ARKANSAS
Department of Finance and Administration
EMPLOYEE DISCLOSURE/CERTIFICATION AND EMPLOYMENT OF FAMILY MEMBERS FORM
INSTRUCTIONS FOR HIRING OFFICIAL:
Please check each table below with the disclosure statement and proceed accordingly for the position finalist(s) prior to a job
offer.
No Approval Required
√ if
applies
Answered “Yes” or Answered “No”
Question 1 and/or 2
Questions 1-9a
* Hiring Official must complete information below and
forward with hire packet to HR.
Approval by HR Manager Only
√ if
applies
Answered “Yes”
Answered “No”
Question 4
Question 1 and 4b
Question 5
Question 1
Question 6
Question 6b
Question 8
Question 9
Question 9a
* Submit the form to your agency Human Resource
Manager for approval with the hire packet .
Approval by appropriate Legislative
Branch and Governor
√ if
applies
Answered “Yes”
Answered “No”
Question 3 and 3a
Question 4 and 4b
Question 1
Question 4 and 1
Question 4b
Question 5
* Submit the form to the Office of Personnel Management
(OPM) for review and submission to the Governor, and if
approved, to the Personnel Subcommittee.
Cannot be Hired
√ if
applies
Answered “Yes”
Answered “No”
Question 3
Question 3a
Question 6 and 6b
Question 7
Question 9 and 9a
* The applicant cannot be hired if one or more of the items
above apply.
This form must be completed by the Hiring Official (Supervisor) for the position finalist(s) prior to a job offer.
Agency/Institution
National Park Community College
Hiring Official
Amy Watson
Position Applied for
Position #
N/A
Pay Grade
N/A
Salary
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.
F-3/F-4 Rev. 06/27/12
501-760-4217
Signature of Agency/Institution Hiring Official
Date
Phone Number
Approved
Disapproved
Signature of Agency/Institution Human Resource Manager
Agency Number
Date
Hiring Official must check that the applicant completed all
required information and answered all questions before signing
form.
*Ensure the date elected for 3b is after employment date.
*Ensure the salary for 4b is correct.
*Ensure spouse is a former
B
Constitutional Officer
C
.
Please initial to confirm: ______
Hiring Official must check that the applicant completed all
required information and answered all questions before signing
form.
Please initial to confirm: ______
Hiring Official must check that the applicant completed all
required information and answered all questions before signing
form.
*Ensure the salary for 4b is correct.
*Ensure the information for 6b is correct.
Please initial to confirm: ______
Hiring Official must check that the applicant completed all
required information and answered all questions before signing
form.
*Ensure 3a was answered before signing below.
*Ensure the information for 6b is correct.
*Ensure the information for 9a is correct.
Please initial to confirm: ______
STATE OF ARKANSAS
Department of Finance and Administration
Employee Disclosure Requirements/Restrictions Notice
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;
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 Rule 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 rule.
National Park Community College Amy Watson
Agency Name Hiring Official
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
F-5/F-6
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's
official 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;
(B) Contract;
(C) Claim; or
(D) 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, where 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 therefore 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.
STATE OF ARKANSAS
Department of Finance and Administration
Employee Disclosure Requirements
In Compliance with Governor’s Executive Order 98-04
Arkansas Code Annotated § 19-11-706
Pursuant to Arkansas Code Annotated § 19-11-706, employees are required to disclose any benefit received from any
state contract. Specifically:
(a) 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) 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.
This employee disclosure shall be made within 30 days after the employee has actual or constructive
notice of a benefit received or to be received. Such disclosure shall be made by completing this Employee Disclosure
Requirements form and forwarding this completed form to:
Director
Department of Finance and Administration
P. O. Box 3278
Little Rock, AR 72203-3278
Employee Name:
Agency Name/ Division where employed: National Park Community College
Name of Person/Business involved with State Contract:
Name of Government Body with which the Business has a Contract:
Dollar Amount and Nature of Contract:
Nature and extent of the benefit received or to be received:
Employee’s Signature Date
F-7
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.
F-8
NATIONAL PARK COLLEGE
DRUG-FREE WORKPLACE POLICY
Drug abuse and use at the workplace are subjects of immediate concern in our society.
These problems are extremely complex and ones for which there are no easy solutions.
From a safety perspective, the users of drugs may impair the well-being of all employees,
the public at large, and result in damage to state property. Therefore, it is the policy of the
State of Arkansas that the unlawful manufacture, distribution, dispensation, possession or
use of a controlled substance in a state agency's workplace is prohibited. Any employees
violating this policy will be subject to discipline up to and including termination. The
specifics of this policy are as follows:
1. State agencies will not differentiate between drug users and drug pushers or sellers.
Any employee who gives or in any way transfers a controlled substance to another person
or sells or manufactures a controlled substance while on the job or an agency premises will
be subject to discipline up to and including termination.
2. The term "controlled substance" means any drug listed in 21 U.S.C. Section 812 and
other federal regulations. Generally, these are drugs which have a high potential for abuse.
Such drugs include, but are not limited to, Heroin, Marijuana, Cocaine, PCP, and "Crack".
They also include "legal drugs" which are not prescribed by a licensed physician.
3. Each employee is required by law to inform the agency within five (5) days after he or
she is convicted for violation of a federal or state criminal drug statute where such violation
occurred on the agency's premises. A conviction means a finding of guilt (including a plea of
nolo contendre) or the imposition of a sentence by a judge or jury in any federal court, state
court, or other court of competent jurisdiction.
4. National Park College must notify the U.S. government agency with which the contract
was made within ten (10) days after receiving notice from the employee or otherwise
receives actual notice of such a conviction.
5. If an employee is convicted of violating any criminal drug statute while in the
workplace, he or she will be subject to discipline up to and including termination.
Alternatively, the agency may require the employee to successfully finish a drug abuse
program sponsored by an approved private or governmental institution.
6. As a condition of further employment on any federal government contract, the law
requires all employees to abide by this policy.
Drug-Free Workplace Agreement
I, __________________________________________________, an employee of
National Park College, hereby certify that I have received a copy of this
agency's policy regarding the maintenance of a drug free workplace. I realize
that the unlawful manufacture, distribution, dispensation, possession or use
of a controlled substance is prohibited on this agency's premises and violation
of this policy can subject me to discipline, up to and including termination. I
realize that as a condition of employment on such federal contact, I must
abide by the terms of this policy and will notify my employer of any criminal
drug conviction for a violation occurring in the workplace no later than five (5)
days after such conviction. I further realize that federal law mandates that
my employer communicate this conviction to the federal agency, and I hereby
waive any and all claims that may arise for conveying this information to the
federal agency.
______________________________________
Print Name
_______________________________________ __________________________
Signature Date
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Npc Hire Packet2015 POISE Payroll System CtrlA=InsertOver

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Completed 15 November 2019

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