South Central Service Cooperative

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Applicant Data Record

Applicant Data Record

SOUTH CENTRAL SERVICE COOPERATIVE
2235 CALIFORNIA AVENUE, SW
CAMDEN, AR 71701
870-836-1600

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, national origin, sex, pregnancy, sexual orientation, gender identity, age, marital or veteran status, disability, genetic information or the presence of a non-job-related medical condition.

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

Soley 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 Fill Out The Applicant Data Record Below

Date of Application

Position Applied For

Referral Source:

Advertisement

Friend

Relative

Walk-In

Employment Agency

Other

Last Name

First Name

Middle

Phone Number

Reaquired field: Address

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Affirmative Action Survey

Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information is voluntary.

Check One:

Male

Female

Check one of the following Race/Ethinic Group:

White

Black

Hispanic

American Indian/Alaskan Native

Asian/Pacific Islander

Other

Check if applicable:

Vietnam Era Veteran

Disabled Veteran

Email a copy to

optional

Required Fields