Employee Application

Employee Application
Employee Profile Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Driver's License Number*
Driver's License Exp. Date*

MonthDayYear
Date
Date of Current Auto Insurance Expiration*

MonthDayYear
Date

Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Address

Street Address

Street Address Line 2

CityState

Zip Code

Network of Community Options, Inc. Mission Statement
Network of Community Options, Inc. is a family-oriented organization working for people with developmental challenges. Network of Community Options, Inc. will fulfill its mission by providing services based on the following core values:

PRIDE

Patience

Respect and Responsibility

Integrity

Dignity

Empowerment

Network of Community Options, Inc. serves Baxter, Clay, Cleburne, Craighead, Faulkner, Fulton, Garland, Greene, Independence, Izard, Jackson, Lawrence, Lonoke, Poinsett, Pulaski, Randolph, Sharp, Stone, Van Buren, White, and Woodruff counties.
Application Process
- Complete the application in its entirety. Incomplete applications will not be processed.
- If an offer of conditional employment is offered to you, you must pass a pre-employment drug screen. NCO, Inc. has a zero-tolerance drug policy.
- All required state, federal, and maltreatment background checks must be passed.
- Applications are kept on file for one year.
- NCO, Inc.'s payroll is distributed via direct deposit. Applicants must have or establish a valid checking or savings account in order to payroll to be processed.
- NCO, Inc. is under no obligation to provide the applicant with an explanation as to why he/she is not selected for employment.
- NCO, Inc. reserves the right to dismiss any applicant upon discovery of misleading or omission of information.
- NCO, Inc. is an at-will employer and can modify employment at any time, providing there is no violation of applicable federal or state law.
- Any questions regarding NCO, Inc.'s application and/or employment processes should be immediately directed to the Human Resources Director at 870.612.5900 ext. 102.
By signing this page, I agree that I have read, understood, and adhere to the above items.
Signature*

Educational Background
High School
Please select highest grade completed.

9101112
College
Highest Degree Obtained
Major

Employment History
Have you ever been previously employed by NCO?*

YesNo
If yes, who was your supervisor?
Do you have any objections to an inquiry of your past employers regarding your character, qualifications, etc?*

YesNo
If yes, which employer and please explain:
Past Employers

List your most recent employment first, followed by previous places of employment.
Employer
Position
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dates of Employment
Supervisor
Reason for Leaving
Employer
Position
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dates of Employment
Supervisor
Reason for Leaving
Employer
Position
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dates of Employment
Supervisor
Reason for Leaving

References

List three references (including one relative):
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Please list any civic affiliations or honors you have received:
Please list any volunteer work you have done that would relate to this position:

Criminal Background Check
DDS is mandated by P.I. 980473 and Act 150 not to employee persons who have been convicted of a felony or misdemeanor involving child abuse or neglect of a child. DDS also recommends that any substantiated report of child abuse or neglect to be considered in determining employment.

Per these guidelines, all applicants hired by NCO, Inc. will have a criminal history background check. Therefore, please note that a conviction of any crime other than a minor traffic violation may disqualify you from employment with Network of Community Options, Inc. Disqualification depends on the relationship of the crime to the position for which you are applying.
At this point, please indicate whether or not you have ever been convicted of any criminal activity.*

YesNo
If yes, please explain:
Agreement

Carefully read this section prior to providing signature below.
I release and authorize NCO, Inc. to request and prepare an investigative report including information as to work history, felony record, and any information appropriate with reference to the job for which I have applied. NCO, Inc. adheres to a drug free environment. A mandatory drug screen is administrated as part of the employment process. Any employment offer will be rescinded from any applicant who fails to comply with this request or who fails to pass the drug screening. I hereby consent to pre-employment drug testing. If I am hired, I hereby consent to any future drug and/or alcohol testing that may be required by NCO, Inc.

I hereby certify that the foregoing statements are true and correct to the best of my knowledge, and I grant NCO, Inc. permission to verify all information. I understand that any misleading or false statements or omission of pertinent information from this application may be considered as sufficient cause for rejection of this application or for dismissal if discovered subsequent to employment.
Applicant Signature*

Employment Reference Check Authorization and Response
Applicant Name*

First NameLast Name
I, HEREBY GIVE CONSENT TO ANY AND ALL PRIOR EMPLOYERS OF MINE, OR MY
CURRENT EMPLOYER, TO PROVIDE THE INFORMATION BELOW WITH REGARD TO MY EMPLOYMENT WITH THE PRIOR OR CURRENT EMPLOYERS TO NETWORK OF
COMMUNITY OPTIONS, INC.

This consent is valid for a period of six months from the date application submitted.
Applicant's Signature*

Agreement to View Medical File
I, First Name* Last Name* , hereby agree to allow the following agencies: Arkansas Department of Human Services: Division of Developmental Disabilities Services, Arkansas Department of Human Services: Division of Child Care and Early Childhood Education Licensing and Accreditation Unit to view the following documents contained in my medical file:
- Drug Screen Results
- Proof of Hepatitis B vaccination or declination of same
I understand these agencies will observe set HIPPA regulations of all information viewed or discussed with the strictest level of confidentiality as set forth in Network of Community Options, Inc. policies.
Employee Signature*

Hepatitis B Vaccination
Please choose one of the following options regarding the Hep-B vaccine. A Hep-B vaccination information sheet will be provided upon request.*

I have been instructed in the benefits of receiving the Hepatitis B vaccination and agree to participate in the vaccination program.I have already been immunized with the Hepatitis B vaccine and will provide a copy of proof of vaccination to the Human Resources Department of NCO, Inc.I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B (HPV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious virus.
Employee Signature*

Code of Ethics
All Network of Community Options, Inc. employees will maintain the highest standards of honesty, integrity, and impartiality in conduct and will assure performance of duties.
1. Employees should remember that they are agency representatives of Network of Community Options, Inc. licensed by the Developmental Disabilities Services.
2. Employees’ fundamental loyalty must be to those served by NCO, Inc. This overrides loyalties to friends, co-workers, and outside groups.
3. Employees’ positions will not be used for personal gain. Their influence and confidential information will not be used for personal advantage.
4. Comprising obligations will be avoided. An NCO, Inc. Employee must never permit himself or herself to be placed under any kind of personal obligation (i.e. acceptance of favors or gifts) which could lead another person to expect special consideration.
5. Employees should pay all their just debts and financial obligations in a proper and timely manner, so that it does not reflect adversely on NCO, Inc. The employee is obligated to guard and honor their personal financial position, and thus avoid any actions that might bring discredit or reflect adversely upon himself or herself and thereby, upon NCO, Inc. If an employee does not pay all just debts and financial obligations in a timely manner, the employee’s paycheck may be garnished by a business corporation or state or federal government through proper court proceedings.
6. No employee shall engage in criminal, infamous, immoral, or notoriously disgraceful conduct (i.e. abuse, language, profanity, gambling, etc...) which jeopardizes the health, safety, or welfare of those signed by NCO, Inc.
7. An employee shall observe the requirements of courtesy, consideration, and promptness in dealing with subordinates and supervisors and must follow the chain of command in all situations. Therefore, the practice of gossiping, spreading rumors, slandering other employees, lying, and other activities are strictly forbidden.
8. Decisions and actions must be determined by impersonal considerations, free from taint of favoritism or prejudice.
9. Personal ambition or unjust criticism must not deter employees from actions, which their consciences indicate are right.
10. An employee’s position obligates the employee to guard the honor of this position. The employee must avoid anything that might bring discredit upon himself or herself and, thereby NCO, Inc.
11. All NCO, In. employees shall not engage in any personal projects during on-duty hours.
12. To avoid possible disruptions, guests will be required to obtain pre-authorization from Program Coordinators, Directors, and/or Supervisors before visiting any of NCO, Inc.’s site locations.
13. All employee will be required to sign that they understand and will follow the above CODE OF ETHICS.
Employee Signature*

Driver Non-Medical Transportation Medical Statement of Understanding
I, First Name* Last Name* , attest that I have no current physical or medical condition, including, but not limited to, vision impairment that cannot be corrected so as to not interfere with any aspect of safe driving, passenger assistance, or the ability to provide emergency treatment to the client or the general public. If at any time my health condition should significantly change so as to directly affect my ability to provide safe transportation, I will immediately contact the Human Resources Department of NCO, Inc. to advise the company of said changes.
Employee Signature*

Employee Acknowledgement of Employee Handbook and Policies
The employee handbook describes important information about NCO, Inc., and I understand that I should consult my immediate department supervisor regarding any questions not answered in the handbook. I have entered into my employment relationship with NCO, Inc. voluntarily and acknowledge that there is no specified length of employment. Accordingly, either I or NCO, Inc. can terminate the relationship at will, with or without cause.

Since the information, policies, and benefits described here are necessarily subject to change, I acknowledge that revisions to the handbook may accrue, except to NCO, Inc.’s policy of employment-at-will. All such changes will be communicated through official notices, and I understand that revised information may supersede, modify, or eliminate existing policies. Only the Executive Director of NCO, Inc. has the ability to implement any revisions to the policies in this handbook.

Furthermore, I acknowledge that this handbook is neither a contract of employment, nor are paper copies provided to employees upon hiring. I understand that NCO, Inc.’s employee handbook is on the company website and was reviewed with me during my new hire orientation. I understand that it is my responsibility to comply with the policies contained in this handbook and any revisions made to it.
Employee Name*

First NameLast Name
Employee Signature*

Memorandum
Date: August 17, 1999

Edited: February 9, 2022

To: All NCO, Inc. Personnel

From: Lisa Pinkston, Executive Director

RE: Drug Free Workplace

Purpose: The purpose of this policy is to comply with the Drug Free Workplace Act of 1988 and Executive Order 89-2.

Scope: This policy is applicable to all Divisions/Offices within the Department of Health and Human Services (DHHS) as well as to any agency receiving grant(s) from the Department of Health & Human Services. All employees are to be made cognizant of this policy. Furthermore, employees are required to sign the Acknowledgement form, and return the signed form to the Human Resources Director.

Policy: Drug abuse use at the workplace is subject of immediate concern in our society. These problems are extremely complex and ones for which there are no easy solutions. From a safety perspective, the users of drugs may impair the well-
being of all employees, the public at large, and result in damage to state property. Therefore, it is the policy of the State of Arkansas that the unlawful manufacturing, distribution, dispensation, possession, or use of a controlled substance in a state
agency’s workplace is prohibited. Any employee violating this policy will be subject to discipline up to and including termination. The specifics of the policy are as follows:
1. State agencies will not differentiate between drug users and drug pushers or sellers. Any employee who gives or in any way transfers a controlled substance to another person or sells or manufactures a controlled substance while on the job or on agency premises will be subject to discipline up to and including termination.
2. The term “controlled substances” means any drug listed in 21 U.S.C. Section 812 and other Federal regulations. Generally, there are drugs, which have a high potential for abuse. Such drugs include, but are not limited to Heroin,
  Marijuana, Cocaine, PCP, and “Crack”. They also include “legal drugs” which are not prescribed by a licensed physician.
3. Each employee is required by law to inform the agency within five (5) days after he or she is convicted for violation of any Federal or State Criminal drug stature where such violation occurred on the agency’s premises. A conviction
  means a finding of guilt (including a plea of nolo contendere) or the imposition of a sentence by a judge or jury in any federal court, state court, or other court of competent jurisdiction.
4. The Department of Health and Human Services (DHHS) must notify the U.S. government agency with which the contract was made within then (10) days after receiving notice from the employee or otherwise receives actual notice
  of such a conviction.
5. If an employee is convicted of violating any criminal drug statue while in the workplace, he or she will be subject to discipline up to and including termination. Alternatively, the agency may require the employee to successfully finish a drug abuse program sponsored by an approved private or governmental institution.
6. As a condition of further employment on any federal government contract, the law requires all employees to abide by this policy.
Department Contact: Any questions concerning this policy should be directed to:

Deputy Director

Division of Management Services

4th Floor Donaghey Plaza West

Slow Number 3400

P.O. Box 1437

Little Rock, AR 72203-1437

Telephone number: 501.682.6576

Acknowledgement: I acknowledge that I have read and understand the above policy regarding a Drug Free Workplace. I further understand that once this sheet is signed, it will be placed in my personnel file.
Signature*

Non-Disclosure of Privileged and Confidential Information Affidavit
To whom these presence may come, be it known that I, First Name Last Name , am an employee of Network of Community Options, Inc., formerly Helping Hands School. By reason of said employment, I will have access to information relative to clients of said Network of Community Options, Inc. including medical records, hospital records, conditions, histories, treatment, diagnosis, prognosis, etc...as may be required to perform my job. I acknowledge that said information acquired by me through my employment or contacts concerning clients of Network of Community Options, Inc. is confidential and as such I agree not to divulge, furnish, or otherwise use this information in any form whatsoever without written authorization from the proper parties.

I further acknowledge and agree that any breach of this confidentially may be considered by my employer as an act of misconduct and as such is sufficient cause for termination of my employment with Network of Community Options, Inc.

I further agree that if and when my employment with Network of Community Options, Inc. is severed by reasons of retirement, termination of employment, or voluntary separation. I will continue to be bound by this Non-Disclosure of Privileged and Confidential Information Affidavit.
I, First Name Last Name , acknowledge that I have read this Non-Disclosure of Privileged and Confidential Information Affidavit and have had the opportunity to discuss any questions that I may have with my employer or others of my choosing; and, as indicated by my signature below, I, hereby, agree to be bound by this affidavit and have received a copy thereof.
Employee Name*

First NameLast Name
Signature*

Payroll and Timekeeping Policy and Procedures
Employee Name*

First NameLast Name
Social Security #*
Position for Employment
- Clock-in and clock-out must be completed via the computerized timekeeping system. This is confirmation of time worked. Failure to clock-in or out may delay processing of payroll.
- If an error occurs or clock-in and/or out is delayed by a work incident, please contact your direct supervisor immediately.
- You must enter your employee pin number as well as your job pin number each time you submit attendance.
- Only clock-in and out from your authorized work location. Clocking-in and/or out from an unauthorized location may result in termination of your employment.
- Do not clock-in and/or out for other employees.
- Do not work more than your scheduled hours without permission from your direct supervisor.
- Remember to clock-in and/or out between each shift.
By signing below, I agree that I have read, understand and adhere to Network of Community Options, Inc. payroll and timekeeping policy and procedures.
Signature*

Authorization for Direct Deposit Payroll
TO: Network of Community Options, Inc.
From:

First NameLast Name
Social Security #
I hereby authorize Network of Community Options, Inc. to deposit my net wages on
each pay date to my account as follows:
Name of Bank
Address of Bank

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Routing #
Account #
Type of Account:

CheckingSavings
This authorization is effective with my pay on the day of the month day of month , 20 year .
Signature

Statement of Understanding
By initializing below, you are stating that you understand each policy as reviewed during New Employee Orientation.
Type a question
Initial   I understand that I must provide NCO, Inc. with a copy of a current Arkansas Driver’s License and a copy of a current proof of automobile insurance.

Initial   Code of Ethics

Initial   Non-Disclosure of Confidentiality

Initial   Drug and Alcohol Use

Initial   Employment At Will

Initial   Annual Training Requirements

Initial   Personal Information Updates

Initial   Paydays

Initial   Grievance procedures

Initial  Job Description

Initial   Administration pay corrections

Initial   Benefits program waiting period

Initial   Excessive use of cell phones

Initial   I understand that upon resignation of employment or retirement, full-time employees are paid for unused PTO up to 240 hours if employee provides a 2 week notice. If an employee is terminated, said employee will not be paid for unused PTO time.

I,   First Name   Last Name   , have been instructed on the policies and procedures of NCO, Inc.
Signature
Should be Empty:

Employee Application

Employee Profile Information

Emergency Contact Information

Network of Community Options, Inc. Mission Statement

Application Process

Application for Employment

Educational Background

Employment History

Past Employers

References

Criminal Background Check

Agreement

Employment Reference Check Authorization and Response

Agreement to View Medical File

Hepatitis B Vaccination

Code of Ethics

Driver Non-Medical Transportation Medical Statement of Understanding

Employee Acknowledgement of Employee Handbook and Policies

Memorandum

Non-Disclosure of Privileged and Confidential Information Affidavit

Payroll and Timekeeping Policy and Procedures

Authorization for Direct Deposit Payroll

Statement of Understanding