Fillable TOS Application2016 Fillable V6 (Arkansas State Treasury)

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TOS Application2016 Fillable V6 (Arkansas State Treasury)

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•
Applications for employment with the Treasurer of 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. All employees of the Treasurer of State are required to
successfully complete a criminal background check.
• 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
Treasurer of State. 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 and the
amendments of the ADAAA, may request any needed accommodations
to participate in the application process.
• Act 228 of 1997 specifies that no person who is required to register with
the Selective Service System shall be eligible for employment by the
State of Arkansas unless the person has signed a statement of selective
service status. It further requires that the statement of selective service
status must be sworn under penalty of perjury that the person is either
registered in accordance with the Military Selective Service Act or
excused from such registration.
Revised 09/2016
ARKANSAS TREASURER OF STATE
EMPLOYMENT APPLICATION
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 page is voluntary.
Applicant’s Name_____________________________________________________________
Date of Birth _____________________________ Male Female
Check one in the list below that you consider yourself to be:
White/Not Hispanic Origin
Black/Not Hispanic Origin
American Indian or Alaskan Native
Asian or Pacific Islander
Hispanic
If you do not you consider yourself to be any of the above, please check “other” below.
Other
Military History
If you believe you may be eligible for veteran’s preference consideration, complete this section. The Arkansas
Veterans Preference Act states specific requirements which must be met in order to be eligible for veteran’s
reference. Under certain conditions, spouses, widows, or widowers of qualified veterans may also be eligible for
veteran’s preference. For consideration of veteran’s preference, proof such as a 00-214, current letter from
Veterans’ Administration or other official documentation may be required. Specific questions regarding veteran’s
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?
Arkansas Job Link or ArStateJobs
Newspaper
Department of Workforce Services
Treasurer of State Website
Educational Institution Name of Institution: __________________________________________________
Other Explain:_______________________________________________________________________
APPLICATION FOR EMPLOYMENT WITH THE ARKANSAS TREASURER OF STATE
Please answer all questions which apply to you. If they do not apply, mark them N/A. Please print or type.
LAST NAME (hit enter)
FIRST NAME
COMPLETE MAILING ADDRESS
CITY
LIST THE POSITION YOU ARE APPLYING FOR: (REQUIRED)
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 Time 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 for which you are applying. Give type of license,
license number, date of expiration, and state.
EDUCATION STATUS SECTION (Required)
HIGH
SCHOOL
Received:
Diploma G. E. D. Certificate: Type Awarded:__________
If None, Highest Grade
Completed:____________
List below post-secondary schools, colleges, universities, trade/vocational, or others attended:
Name and Location
Major/Minor
Hours Completed (See
note below)
Year Graduated
Degree or Diploma
Awarded
Note: For hours completed, indicate whether semester hours, quarter hours, clock hours, etc.
A transcript of your most recent coursework should be attached to this application.
Revised 09/2016
HOME PHONE WORK PHONE PERSONAL CELL PERSONAL EMAIL
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 volunteer or unpaid work as part of your work history; however, you should include the
number of hours per week which you performed these duties. Resume may not be substituted for completion of
application form, but may be included.
1.
Current of most recent employer
Business Phone Number
EMPLOYMENT DATES
From _____________________
Month Year
To ________________________
Month Year
Complete mailing address
City
State
ZIP Code
Type of business
Average hours worked per week
Supervisor’s name
Name under which employed
Your job title
Salary
$________________$________________
Lowest Highest
Your job duties (be specific)
Reason for Leaving
2.
Former employer
Business Phone Number
EMPLOYMENT DATES
From _____________________
Month Year
To ________________________
Month Year
Complete mailing address
City
State
ZIP Code
Type of business
Average hours worked per week
Supervisor’s name
Name under which employed
Your job title
Salary
$________________$________________
Lowest Highest
Your job duties (be specific)
Reason for Leaving
3.
Former employer
Business Phone Number
EMPLOYMENT DATES
From _____________________
Month Year
To ________________________
Month Year
Complete mailing address
City
State
ZIP Code
Type of business
Average hours worked per week
Supervisor’s name
Name under which employed
Your job title
Salary
$________________$________________
Lowest Highest
Your job duties (be specific)
Reason for Leaving
. Resume may not be substituted for completion of application form, but may be included.
4.
Former employer
Business Phone Number
EMPLOYMENT DATES
From _____________________
Month Year
To ________________________
Month Year
Complete mailing address
City
State
ZIP Code
Type of business
Average hours worked per week
Supervisor’s name
Name under which employed
Your job title
Salary
$________________$________________
Lowest Highest
Your job duties (be specific)
Reason for Leaving
5.
Former employer
Business Phone Number
EMPLOYMENT DATES
From _____________________
Month Year
To ________________________
Month Year
Complete mailing address
City
State
ZIP Code
Type of business
Average hours worked per week
Supervisor’s name
Name under which employed
Your job title
Salary
$________________$________________
Lowest Highest
Your job duties (be specific)
Reason for Leaving
6.
Former employer
Business Phone Number
EMPLOYMENT DATES
From _____________________
Month Year
To ________________________
Month Year
Complete mailing address
City
State
ZIP Code
Type of business
Average hours worked per week
Supervisor’s name
Name under which employed
Your job title
Salary
$________________$________________
Lowest Highest
Your job duties (be specific)
Reason for Leaving
. Resume may not be substituted for completion of application form, but may be included.
SPECIAL SKILLS: Put a check beside business machines you can operate and software you are trained to use -
add additional under “other.”
computer (laptop/desktop) 10 key adding machine copier scanner
shredder fax machine printer multi-line phone
Microsoft Office Suite Word Excel graphics programs
Access Internet research accounting programs
other ________________________________________________________________________________
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.
.
Name
Relationship
DISCLOSURE REQUIREMENTS: Governor’s Executive Order 98-04, Governor’s Policy Directive #8, and ACA §21-8-
304 require 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 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.
Name
Relationship
NEPOTISM:
Do you have any relatives employed by the
Treasurer of State? Yes No If yes,
complete the remainder of this section and list
name(s) at right
(This question is being asked for the sole purpose of ensuring compliance with
any applicable law or policy concerning nepotism.)
2. Are any of your relatives one of
the following: If yes, check & list at
right.
Current constitutional officer
Current state employee
Current member of the AR General Assembly Former member of the General Assembly
(Former refers to employment during most Former constitutional officer
Recent two years) Former state employee
AASIS
Before you sign this application
Check over your answers to make sure that all the 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 understand that if I state I have a college degree, and do not have one, my application may be rejected or, if hired, I may
be terminated in accordance with Arkansas Code 21-12-102.
I understand that false, misleading, or incomplete statements could lead to my dismissal as an employee or rejection as
an applicant.
I affirm that it is my genuine intent to seek employment with the Arkansas Treasurer of State, and this application is
submitted solely for that purpose and for no other purpose.
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. _________________ (Applicant’s initials)
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
§25-16-1005.
I understand that if I am hired, my employment is not for any definite period of time, and I may be terminated at any time.
___________________ (Applicant’s initials)
I understand that my application may be subject to disclosure as a public record under the Arkansas Freedom of
Information Act.
I understand that the Treasurer of State's Office may impose additional requirements as a condition of application or
employment. _____________________ (Applicant’s initials)
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. ______________________ (Applicant’s initials)
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. ___________________ (Applicant’s initials)
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.
___________________ (Applicant’s initials)
(If the sections above are not initialed, this application will be held and not considered until this page is complete.)
Signature of applicant
Date of signature
Arkansas Treasurer of State
State Capitol Little Rock, Arkansas 72201 (501) 682-5888
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 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 1997 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 of Act 228 of the 1997 Acts of the Arkansas General Assembly.
Applicant MUST check applicable box(es).
I am a 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
I am a male, currently registered for Selective Service
Other, please specify
______________________________________________________________
______________________________________________________________
______________________________________________________________
_________________________________ ________________________________
Name (Please Print) Date
_________________________________
Signature
Eff. 09/2016
The Arkansas Treasurer of State is an Equal Opportunity Employer.
An application will be given employment consideration only if the applicant
completes the entire application and indicates the job title for which he or she is
making application. The applicant must sign and date each application. Resumes are
accepted to supplement the application, but should not be submitted in place of the
application.
Employment applications postmarked by 4:30 p.m. on the closing date of any
advertised vacancy will be accepted for consideration of the vacancy. The Treasurer
of State is not responsible for delayed delivery by any postal service.
The application will be kept on file for six months. After that time, the applicant must
re-apply to be considered for vacancies.
To notify applicants selected for interviews, the applicant will be contacted via the
phone numbers and addresses provided on this application. If contact cannot be
made after reasonable effort, the applicant will be removed from consideration for
employment.
This application Should Be Returned To The Address Shown Below.
Notice to Applicants
For Employment with the
Arkansas Treasurer of State
HUMAN RESOURCES
ARKANSAS TREASURER OF STATE
1401 WEST CAPITOL, SUITE 275
LITTLE ROCK, AR 72201
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TOS Application2016 Fillable V6 (Arkansas State Treasury)

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Completed 28 July 2020

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