lication

or mployment

SOUTH CENTRAL SERVICE COOPERATIVE

400 Maul Road

Camden, AR 71701

870-836-1600

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap.

(PLEASE PRINT)

Date of Application ____________ _

Position(s) Applied For _________________ Location: __________ _

Referral Source: 0 Advertisement D Friend 0 Relative Walk-In

D Employment Agency D Other _____________ _

Name--------------------------------------LAST FIRST MIDDLE

Address NUMBER STREET CITY STATE Z!P CODE

Telephone _( ______________ Social Security Number Area Lode

Cell Number If employed and you are under 18, can you furnish a work permit? D Yes D No

Have you filed an application here before? D Yes D No

Have you ever been employed here before? D Yes L No

If Yes, give dace ______ _

If yes, give date ______ _

Are you employed now? OYes ONo May we contact your present employer? 0 Yes D No

Are you prevented trom lawfully becoming employed in this country because of Visa or Immigration Status? 0 Yes D No (Proof of citizenship or immigration status may be required upon employment.)

On what date would you be available for work? ____________ _

Are you available to work DFull Time 0 Part-Time

Are you on a lay-off and subject ro recall? D Yes D No

Can you travei if a job requires it? D Yes D No

0 Shift Work

Have you been convicted of a felony within the last 7 years? D No D Yes (Conviction will not necessarily disqualify applicant from employment.)

D Temporary

If Yes, please explain -------------------------------

A llJ P()JTA l ()PPORTITI\JlTV JH,KDI f'\Vl:ID

Veteran of the US Military service? Yes [J No If Yes, Branch ________ _

Indicate languages you speak, read, and/or write.

FLUENT GOOD FAIR

SPEAK

READ

WRITE

List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex or national origin): _ _ _ _ _ _

Please provide name, address and telephone number of three references who are not related to you and are not previous employers. Also include a resume and copies of any appropriate license with this application.

Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals 'With Physical Or Mental Handicaps.

Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, asamended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals.

If you are a disabled veteran, or have a physical or mental handicap, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job to the best of your ability in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment.

If you wish to be identified, please sign below.

Handicapped Individual Disabled Veteran 17 LJVietnam Era Veteran

Signed __________________ _

Veteran Preference Information

For purposes of this policy, “veteran” is defined as: a. A person honorably discharged from a tour of active duty, other than active duty for training only, with the

armed forces of the United States; orb. Any person who has served honorably in the National Guard or reserve forces of the United States for a period

of at least six (6) years, whether or not the person has retired or been discharged.

In accordance with Arkansas law1, please indicate if you are: 1. a veteran without a service-connected disability; Yes� No�

2. a veteran with a service-connected disability; or Yes� No�

3. a deceased veteran’s spouse who is unmarried throughout the hiring process Yes� No�

In order for an applicant to receive the veteran’s preference, the applicant must be a citizen and resident of Arkansas, be substantially equally qualified as other applicants and do attach the following documentation, as applicable, to the employment application:

• Form DD-214 indicating honorable discharge;• A letter dated within the last six months from the applicant’s command indicating years of service in the

National Guard or Reserve Forces as well as the applicant’s current status;• Marriage license;• Death certificate;• Disability letter from the Veteran’s Administration (in the case of an applicant with a service-related

disability).

1

2

3

4

Employment xper1ence

Start with your present or last job. Include military service assignments and volunteer act1vmes. Exclude organization names which indicare race, color, religion, sex or national origin.

Employer Telephone Dates Employed

) From To Work Performed

Address

Job Title Hourly Rate /Salary

Starting Final

Supervisor

Reason for Leaving

Employer Telephone Dates Employed

) From To Work Performed

Address

Job Title Hourly Rate /Salary

Starting Final

Suptrvisor

Renson for Leaving

Empk,ver Tdephone Dates Employed

( ) From To Work Performed

Address

Job Tide Hourly Rate /Salary

Starting Final

Supervisor

Reason for Leaving

Employer Telephone Dates Employed

( ) From To \Vork Performed

Address

Job T'ti� Hourly Rate /Salary

Starring Final

Supervisor

Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.

Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience

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Applicant

ata ecor

SOUTH CENTRAL SERVICE COOPERATIVE

2235 California Avenue SW

Camden, AR 71701

870-836-1600 FAX: 870-836-1600

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap.

As employers/ government contractors, we comply with government regulations and affirmative action responsibilities.

Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

(PLEASE PRINT)

Date ____________ _

Position(s) Applied For ------------------------------

Referral Source: Advertisement D Friend D Relative □ Walk-In

D Employment Agency Other

Name _________________________ Phone (_. ___ _____ _ LAST FIRST MIDDLE Are.1 Cndc

Address NUMBER STRElcT CITY STATF /II' (Olli·

Affirmative Action Survey

Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of app;icants.

This data is for analysis and affirmative action onl y . Submission of information is voluntary .

Check one:

D Male Female

C!:eck one of the following:

Race/Ethnic Group: White Black f I L _j Hispanic

American Indian/ Alasbn Native

Check if any of the following are applicable:

□Vietnam Era Veteran □Disabled Veteran

Asian/Pacific Islander

[1 Handicapped Individual