EMPLOYMENT APPLICATION

University of Arkansas at Fort Smith

Human Resources 5210 Grand Avenue P.O. Box 3649 Fort Smith, Arkansas 72913-3649 479-788-7083 www.uafortsmith.edu

Applications for employment with the University of Arkansas at Fort Smith are accepted without regard to sex, race or color, national origin, handicap/disability, age, religion, or political affiliation. 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 University of Arkansas at Fort Smith. If any individual is hired, he/she is an employee at-will and may be terminated at any time without cause. An employees status as an employee at-will cannot be changed to an employee for a definite term except by a contract signed by the chancellor of the University. 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. The form must be returned, even if left blank. Applicants name Social Security number Date of birth
s

Male

Female

Check one of the six (6) races listed which you consider yourself to be.

Asian or Pacific Islander Black (non-Hispanic) Hispanic American Indian or Alaskan Native White (non-Hispanic) Nonresident Alien

Military History
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 the 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. 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?

Newspaper

Please specify

Employment Security Department University Job Vacancy announcement Internet Other

Revised 5/02

Please specify site Name of institution

Educational institution
Explain

APPLICATION FOR EMPLOYMENT

NAME: Last

Please answer all questions which apply to you. If they do not apply, mark them N/A. Print, type, or write legibly. Incomplete applications WILL NOT be considered. Misleading or incomplete statements could lead to your rejection as an applicant or your subsequent dismissal as an employee.
First Position(s) Applying For: City Work Phone Number ( ) Message or Other Phone Number ( ) State E-mail Address ZIP Code Middle Initial Preferred First Name

Social Security Number Complete Mailing Address Home Phone Number ( s )

EMPLOYMENT STATUS
Part-Time Temporary Yes Yes Yes Yes Yes Yes Evening No No No No No No

Are you available to work: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full-Time

Have you ever filed an application for employment with the University of Arkansas at Fort Smith? . . . . . . . . . . . If yes, give date(s) and name (if different) Have you ever been employed at the University of Arkansas at Fort Smith? . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, give date(s) and name (if different) Have you ever been employed by another state agency or college in Arkansas? . . . . . . . . . . . . . . . . . . . . . . . . Are you a United States citizen or an alien who has the legal right to work in the job for which you are applying? (Proof of citizenship or immigration status will be required upon employment.) . . . . . . . . . . . . . . . . . . . Have you ever been convicted of a felony? (Conviction will not necessarily disqualify applicant from employment.) . . . . May we contact your current employer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If no, please understand that all job offers are contingent upon a final reference (employment verification) from your current employer. If you indicate no, you will be notified before your current employer is contacted. s

EDUCATIONAL HISTORY
From Mo. Yr. To Mo. Yr. Course of Study Did you Graduate? Diploma/Degree Received

Name and Address of School

PROFESSIONAL LICENSURE
License No.
Page 1 of 4

Type of Licensure:
Revised 12/03

State

Expiration Date

IMPORTANT - Rsums may be attached but will not be considered as a substitute for a complete application form. List all your 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 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.
s

WORK HISTORY
Current or most recent employer City Supervisors name Job title Business phone State ZIP Code Employment dates From Month Year Year To Month Average hours worked per week Rate of Pay

1.

Complete mailing address Type of business Name under which you were employed Reason for leaving Job duties

$ Lowest

$ Highest

2.

Next most recent employer City Supervisors name Job title

Business phone State ZIP Code

Employment dates From Month Year Year To Month Average hours worked per week Rate of Pay

Complete mailing address Type of business Name under which you were employed Reason for leaving Job duties

$ Lowest

$ Highest

3.

Next most recent employer City Supervisors name Job title

Business phone State ZIP Code

Employment dates From Month Year Year To Month Average hours worked per week Rate of Pay

Complete mailing address Type of business Name under which you were employed Reason for leaving Job duties

$ Lowest

$ Highest

4.

Next most recent employer City Supervisors name Job title

Business phone State ZIP Code

Employment dates From Month Year Year To Month Average hours worked per week Rate of Pay

Complete mailing address Type of business Name under which you were employed Reason for leaving Job duties

$ Lowest

$ Highest

Page 2 of 4

5.

Next most recent employer City Supervisors name Job title

Business phone State ZIP Code

Employment dates From Month Year Year To Month Average hours worked per week Rate of Pay

Complete mailing address Type of business Name under which you were employed Reason for leaving Job duties

$ Lowest

$ Highest

6.

Next most recent employer City Supervisors name Job title

Business phone State ZIP Code

Employment dates From Month Year Year To Month Average hours worked per week Rate of Pay

Complete mailing address Type of business Name under which you were employed Reason for leaving Job duties

$ Lowest

$ Highest

SPECIAL SKILLS
Typing ________ (wpm)

SKILLS (that you believe are related to the job for which you are applying) Shorthand ________ (wpm) Office equipment you can operate Software applications: Are there any other experiences, skills, or abilities that you feel especially qualify you for work with our company?

PROFESSIONAL REFERENCES
Business Address Telephone

Please list four (4) persons knowledgeable of your qualifications to fill the position for which you are applying.
Name & Occupation

1.

2.

3.

4. s

NEPOTISM
No Yes
If yes, complete the remainder of this section.
Department Relationship

Do you have any relatives employed by the University of Arkansas at Fort Smith?
Name

Page 3 of 4

PART-TIME FACULTY APPLICANTS ONLY

Days Fort Smith

Complete the following information if applying for part-time teaching assignments. I am available to teach: I am available to teach at: s

Evenings Booneville

Weekends County Line

Ozark

Paris

Waldron

Other

REFERENCE CONSENT AND RELEASE

I, _________________________________________________ , hereby give consent to any and all prior (and/or current) employers of mine to provide information regarding my employment with prior (and/or current) employers to the University of Arkansas at Fort Smith. This consent is valid for a period of six (6) months from the date indicated below. A copy of this form shall serve as an original.

Name (Please Print)

Social Security Number

Signature

Date

Before you sign this application:

Please 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 will be required. 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 false, misleading, or incomplete statements could lead to my subsequent dismissal as an employee or rejection as an applicant. I understand that if I am hired, I am an employee at-will and that my employment is not for any definite period of time, and I may be terminated at any time without cause. My status as an employee at-will, who can be terminated at any time without cause, cannot be changed by any person or act except by a written contract signed by the chancellor of the University. 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 drivers safety record, and that if my current or future drivers record is unacceptable under the State Drivers 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 my former employer(s) will be contacted. I also understand that some jobs require special background checks, security clearance, or compliance with other institution 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 I am in compliance with the State Military Selective Service Act. I affirm that it is my genuine intent to seek employment at the University of Arkansas at Fort Smith, and this application is submitted solely for that purpose and for no other purposes.

Signature

Date

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED

FOR HUMAN RESOURCES USE ONLY Copies to: JVN
Page 4 of 4

STATE OF ARKANSAS Department of Finance and Administration

EMPLOYEE DISCLOSURE/CERTIFICATION AND EMPLOYMENT

1. Are you a current state employee? 2. Are you a former state employee?

OF

FAMILY MEMBERS FORM

Yes Yes Yes Yes Yes Yes Yes

Answer the following questions regarding your current, former* and future employment with the State of Arkansas:

No No No No No No No

3. Are you a current member of the Arkansas General Assembly (House or Senate) or a current Constitutional Officer?** 4. Are you the spouse of a current member of the Arkansas General Assembly or spouse of a current Constitutional Officer? __________________________________________ (Member/Officer Name) If yes, is your expected salary above the pay grade 13, level IV? 5. Are you a former member or the spouse of a former member _______________________ (Member Name) of the Arkansas General Assembly (House or Senate)? If yes, did you serve or did your spouse serve within the last 24 months? If yes, during the previous 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 it authorized by legislative action? 6. Are you an immediate family member*** (other than the spouse) of a member of the Arkansas General Assembly of a Constitutional Officer? If yes, _____________________________________________ (Member/Officer Name) 7. Are you an immediate family member of a state employee, state board, or Commission member? If yes, _____________________________________________ (Member Name) 8. Are you a relative of the supervisor or hiring official, or will this position have supervisory responsibility over a relative disclosed above? a) If yes, are you a spouse of a member of the Arkansas General Assembly or a Constitutional Officer? _____________________________________________ (Member/Officer Name)
OR

Yes Yes Yes

No No No

Yes Yes

No No

b) If yes, are you an immediate family member (other than the spouse) of a member of the Arkansas General Assembly, a Constitutional Officer, a state employee, or board or commission member? a) If yes, what is the relationship and name? __________________________________________________

Yes

No

* Former is defined as within the last 24 months. ** Constitutional Officer: Governor, Lt. Governor, Secretary of State, Attorney General, Auditor, Treasurer, Land Commissioner. *** Immediate family member includes: spouse, mother, father, sister, brother, child, mother-in-law, father-in-law, sister-in-law, brother-in-law, daughter-in-law, and son-in-law.
I understand that to be eligible for employment with the State of Arkansas, I must be in compliance with Governors Executive Order 98-04, Governors Policy Directive No. 8 and Arkansas Code Annotated 21-8-304, which state, in part, that, while employed as a state employee, I cannot enter into any Professional Services Contract or Consultant Service Contract with any state agency unless I am providing Nursing Services and contracting with the Department of Human Services. I assert that I have answered the above questions to the best of my knowledge, and I understand that failure to disclose this information may result in disciplinary action, if I am hired by this agency.

Signature of Applicant INSTRUCTIONS FOR HIRING OFFICIAL:

Social Security Number

Date

A. Regardless of the answer in #1 or #2, complete this form. Submit this form with the hire packet. B. If applicant marked #3 Yes, this person cannot be hired. C. If applicant marked all items in #4 Yes, complete this form and submit to Chief Fiscal Officer (CFO) and Joint Budget Committee (JBC)/Legislative Council (LC) for approval. Submit approved form with hire packet. D. If applicant marked all items in #5 Yes, this person cannot be hired. E. If applicant marked #6, #7, or #8b Yes, complete this form and submit to agency director, Submit approved form with hire packet. F. If applicant marked #8a Yes, complete this form and submit to CFO and JBC/LC for approval. Submit approved form with hire packet. G. If applicant marked any item in #3, #4, #5, #6, #7, #8a or #8b No, no further action is needed. Submit this form with the hire packet. Agency/Institution Hiring Official

Position Applied for Position # Pay Grade 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. Signature of Agency/Institution Hiring Official Phone Number

Approved Disapproved Agency/Institution Director or Designee Agency Number Date