South Central Service Cooperative Applicant Data Record Form

Applicant Data Record
Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, 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 apreciate your cooperation.

This data is for peridoic government reporting and will be kept in a Confidential File separate formt eh Application for Employment.
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Applied For*
How were you referred to us?*

AdvertisementWalk-InFriendEmployment AgencyRelativeOther (please specify)
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:*

MaleFemale
Check one of the following Race/Ethnic Groups:*

WhiteBlackHispanicAmerican Indian/Alaskan NativeAsian/Pacific Islander
Check if any of the following are applicable:

Vietnam Era VeteranDisabled VeteranHandicapped Individual
Veteran Preference Information
For purposes of this policy, "veteran" is defined as:
1. A person honorably discharged from a tour of active duty, other than active duty for training only, with the armed foreces of the United States; or
2. 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:

	Yes	No
a veteran without service-connected disability;
a veteran with a service-connected disability; or
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 and resident of Arkansas, be substatially 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).
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Resume and Files

Cancelof
Should be Empty:

Applicant Data Record

Affirmative Action Survey

Veteran Preference Information