Please fill out the information below to apply for a position with
Lawrence County Cooperative School, Inc.

Applicant Information

Area of Interest: *check all that apply

Area of Interest

Position Type: *Check any you are willing to accept

Position Type

Availability: *Check any you are willing to accept

Weekdays
Split Shifts
Education
High School:

High School:

Did you graduate?
College

College:

Did you graduate?
Did you graduate?
Prior Employment

Please give accurate, complete full time and part time employment record; start with the most present or most recent employer. Please include any previous employment with Lawrence County Cooperative School, Inc. and any other previous employer.

Personal References

(NAME THREE PERSONS NOT RELATED TO YOU WHOM YOU HAVE KNOWN AT LEAST 1 YEAR)

(THIS IS IN COMPLIANCE WITH TITLE VI & TITLE VII OF THE CIVIL RIGHTS ACT OF 1964)
I hereby give permission for EMPLOYMENT & PERSONAL reference verification on the above

Lawrence County Cooperative School, Inc. DOES NOT discriminate because of Sex, Race, Creed, Age, National origin, Religion, Handicap, or Veteran Status.

Additional Information

Referred to us by:

Name of any friends and relatives employed by Lawrence County Cooperative School.

Are you legally eligible for employment within the United States?
Do you have a valid Arkansas Driver’s Licenses:
Have you ever been convicted of a misdemeanor or felony offense(s) in a court of law or military adjudication?
Have you ever been reprimanded or otherwise disciplined by a previous employer for violation of department or company policy?

Pursuant to House Bill 1032, please indicate if you are responsible for child support or health insurance coverage for a minor dependent(s)?

Child Support:
Health Insurance:

I understand that employment is subject to verification of lawful age and legal right to work in the United States. I will submit such documents as may be necessary to verify same.  Initial each section below as you have read it and agree to it.

DRUG SCREEN –All jobs are safety sensitive and medical marijuana use is prohibited.  I agree to submit (as LCCS policy states) to a drug test and hereby authorize the medical contractor performing the test to provide Lawrence County Cooperative School, Inc. a complete record and/or report. I understand that my conditional offer of employment is subject to the satisfactory completion of the drug test in compliance with the Lawrence County Cooperative School, Inc. Drug & Alcohol Free Work Place policy. If conditional offer of employment is offered I acknowledge I am still subject to LCCS policy of random and “for-cause” drug screens.
EMPLOYMENT SCREEN – I authorize Lawrence County Cooperative School, Inc., its employees, assigns, and agents to conduct an investigation of the information contained in this application or other matters concerning my past employment or other activities and to obtain or direct issuance of reports or other statements which may be furnished or obtained concerning same. I hereby release from liability and responsibility all persons, companies or corporations supplying such information and Lawrence County Cooperative School, Inc. in obtaining such information, and hereby release an law enforcement agency, the various military services, and/or their agents from liability of any kind for damages which may result from furnishing information about me.

CONVICTION STATEMENT – I understand that Lawrence County Cooperative School, Inc. is mandated to a Child Maltreatment Checks, Adult Maltreatment Checks, Criminal Background Checks, and Motor Traffic Record checks which may subject me to be disqualified depending upon the relationship of the report

EMPLOYMENT AT WILL - I understand and agree that if employed, and as a condition of my employment, the employment will be “at will”. That is, either I or Lawrence County Cooperative School, Inc. may end the employment relationship at any time, for any reason, or for no reason. I further understand that no representatives of Lawrence County Cooperative School has authority to enter into any agreement with me for any specific period of time or make any agreement with me contrary to the foregoing. I understand that nothing contained in my employment application or in the granting of an interview is intended to create an employment contract between Lawrence County Cooperative School, Inc. are intended by reason of their publications to confer any rights or privileges to said benefits or policies, or to entitle me to be or remain employed by Lawrence County Cooperative School, Inc. or provisions in the handbook are procedural or are a guideline and Lawrence County Cooperative School, Inc. has the right to change any policy benefits or procedure at any time without notice

TRUTH STATEMENT - I understand that any misleading or incorrect statements render this application void in the event of my employment prior to discovery of any falsehood regarding statements and records about and/or for me. I understand such activity is cause for immediate dismissal.

I have carefully read the above and fully understand the same

I certify that all statements on this application and supporting information in it are true and complete to the best of my knowledge.

Date of Signature