UNIVERSITY OF ARKANSAS AT PINE BLUFF

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Employment Application

APPLICANT INFORMATION

Last Name

First Name

Middle Name

Mailing Address

City

State

Zip

Country

Phone number

Message Number

Work Number

Email Address

List position title(s) and number(s)

1.Job Title

Job#

EMPLOYMENT STATUS

	Yes	No
Will you accept employment anywhere in the United States?

	Full Time	Part-time	Temporary
Check which employment type you will accept:

	Yes	No
Have you ever filed an application for employment with this agency?

What was your name at the time?

	Yes	No
Have you ever been employed by Arkansas State Government?

List the name of the organization

	Yes	No
May we contact your current employer?
May we contact your former employer?

EDUCATIONAL HISTORY

High School:

Diploma

GED

If non, what is the highest grade completed

College and Address

If not applicable type N/A or None.

Major/Minor

Hours

Degree/Diploma Awarded

Employment Application

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

Work History

Current or most recent employer

Business phone number

Complete mailing address

City

State

Zip Code

Employment Information

Employment dates:

From

To:

Average hours worked per week

Salary:

Lowest

Highest

Type of business

Supervisor's name

Name under which employed

Your Job title

Your job duties (be specific)

Reason for leaving

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Employment Application

Have you ever been convicted of a felony?

YesNo

Special Skills

Typing speed (wpm):

Can you use a transcription machine?

YesNo

List the business machines, computers, and word processing software you can operate:

List any other skills relative to the job(s) for which you are applying:

List professional license(s) relevant to position(s) for which you are applying; give type, number, and expiration date:

References

List three (3) person not relate 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

Phone#

E-mail

Name

Address

Phone#

E-mail

Name

Address

Phone#

E-mail

Name

Address

Phone#

E-mail

Nepotism

Do you have a relative(s) employed by the state agency to which you are submitting this application for employment?

YesNo

If yes, complete the remainder of this section:

Name

Relation

Agency employed by

Name

Relation

Agency employed by

Name

Relation

Agency employed by

Military

If you believe you may be eligible for veteran’s preference consideration in accordance with the Arkansas Veterans preference Act complete this section and be prepare to provide the proof of eligibility. 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, or other official documentation may be required.

Have you served on active duty in the United States military, excluding Active Duty for Training (AcDuTra) and Reserve Military Annual Training (AT)?

NoYes

Branch of service

Date of entry

Type of discharge

Date of Discharge

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Employment Application

Check over your answers to make sure all questions have been properly completed.

Have you been employed by any school or entity that is a part of the University of Arkansas system?

NoYes

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 the information on this application is complete, true and accurate.

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 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 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.

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