South Central Service Cooperative

Please Fill Out The Application For Employment Below

Name

Date of Application

Reaquired field:

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Telephone (Cell and/or Home)

Social Security Number

Date of Birth

Position(s) Applied For

Referral Source:

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Friend

Relative

Walk-In

Employment Agency

Other

Have you filed an application here before?

Reaquired field: Yes

Reaquired field: No

If yes, give date:

Have you ever been employed here before?

Reaquired field: Yes

Reaquired field: No

If yes, give date:

Are you employed now?

Reaquired field: Yes

Reaquired field: No

May we contact your present employer?

Reaquired field: Yes

Reaquired field: No

Are you prevented from lawfully becoming employed in this country because of VISA or Immigration Status? (Proof of citizenship or immigration status may be required upon employment.)

Reaquired field: Yes

Reaquired field: No

On what date would you be available for work?

Are you available to work:

Reaquired field: Full Time

Reaquired field: Part-Time

Reaquired field: Temporary

Can you travel if the job requires it?

Reaquired field: Yes

Reaquired field: No

Reaquired field: Not Applicable

Have you been convicted of a felony? (Conviction will not necessarily disqualify applicant from employment.)

Reaquired field: Yes

Reaquired field: No

If yes, please explain:

Veteran of the U.S. Military service?

Reaquired field: Yes

Reaquired field: No

If yes, what Branch?

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

WORK REFERENCES

1. Provide name, address, and phone number of "work reference," who is not related to you.

2. Provide name, address, and phone number of "work reference," who is not related to you.

3. Provide name, address, and phone number of "work reference," who is not related to you.

CHARACTER REFERENCES

1. Provide name, address, and phone number of "character reference" not related to you and who is not a previous employer.

2. Provide name, address, and phone number of "character reference" not related to you and who is not a previous employer.

3. Provide name, address, and phone number of "character reference" not related to you and who is not a previous employer.

Additional Documents Needed for Application Process

Resume

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Required License/Certifications

If you are applying for a position that requires licensure or certification, please upload documents here.

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Veteran/Veteran's Preference Information

Special Employment Notice to Disabled & 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 disable veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, 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 check all that apply and sign below.

Handicapped Individual

Disabled Veteran

Vietnam Era Veteran

For purposes of this application, "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 the United States; or b. 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 law, please indicate if you are:

1. a veteran without a service-connected disability;

2. a veteran with a service-connected disability; or

3. a deceased veteran's spouse who is unmarried throughout the hiring process

In order for an applicant to receive the veteran's preference, the applicant must be a citizen of Arkansas, be substantially equally qualified as the other applicants and must attach/upload 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 Gard 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.

Veteran's Preference Documentation

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Employment Experience - Start with your present or last job. Include military service assignments and volunteer activities. Exclude organizations names which indicate race, color, religion, sex or national origin.

Current or Last Employer

Telephone Number

Reaquired field:

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Supervisor's Name

Position Held

Reason for Leaving

Start Date

End Date (If Applicable)

Starting Salary/Hourly Rate

Final Salary/Hourly Rate

Worked Performed:

Previous Employer

Telephone Number

Reaquired field:

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Supervisor's Name

Position Held

Reason for Leaving

Start Date

End Date (If Applicable)

Starting Salary/Hourly Rate

Final Salary/Hourly Rate

Worked Performed:

Education - Highest Degree/Course Work Completed

Applicant's Statement

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize an investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment. In the event of employment I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

Signature of Applicant

Date

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