Personnel Screening Committee Data Statement County Extension Agents	EPERS-126 3/17/04
Position for which applying	Vacancy Number
Title	County
Name	County
Present Title	Date of initial CES Appointment
Employment Record
List positions held beginning with latest position. List each Extension assignment separately. List non-Extension experience if appropriate. Attach additional pages if necessary.
Position	Major Responsibilities
1
Location
County
From	To
2
Location
County
From	To
3
Location
County
From	To
4
Location
County
From	To
5
Location
County
From	To
The Arkansas Cooperative Extension Service offers its programs to all eligible persons regardless of race, color, sex, gender identity, sexual orientation, national origin, religion, age, disability, marital or veteran status, genetic information, or any other legally protected status, and is an Affirmative Action/Equal Opportunity Employer.
Academic Record
List all college degrees received.
Name of Institution	Degrees Conferred	Major Area of Study
List other college training taken for credit.
Name of Institution	Credit Course	Hours
Other Educational Experiences
List other educational experiences that you feel might assist you in performing the job for which you are applying.
List professional organizations to which you belong and describe other professional and community involvement that you feel is pertinent.
Job Responsibilities
Review the Supplemental Job Description. Describe how your training and/or experience has prepared you to carry out responsibilities in the following areas.
I. Subject Matter
II. Supervisory
III. Organizational relationships
Personnel Comments
Enter any additional information you would like to have considered by the screening committee regarding your qualifications and why you wish to be considered for the position.
Signature	Date
The Arkansas Cooperative Extension Service offers its programs to all eligible persons regardless of race, color, sex, gender identity, sexual orientation, national origin, religion, age, disability, marital or veteran status, genetic information, or any other legally protected status, and is an Affirmative Action/Equal Opportunity Employer.