Pulaski County Human Resources
Mary Ann Zakrzewski

201 S. Broadway, Suite 100
Little Rock, AR 72201
Phone: (501) 340-6110
Fax: (501) 340-6033

Pulaski County Information for Supervisors and Employees

Forms for County Employees

APERS Enrollment Change Request

Cafeteria Waiver/Enrollment

Direct Deposit Authorization Form

Direct Deposit Sign-Up Sheet

FMLA – Application for Leave of Absence

FMLA – Certification of Health Care Provider – Employee’s Serious Health Condition

FMLA – Certification of Health Care Provider-Family Member’s Health Condition

Jim Dailey Fitness Center Membership

Jim Dailey Fitness Center- Change Membership

Request for Seminar-Workshop-Conference Expense

Pulaski County Personnel Policy

Pulaski County Purchasing Policy

Tuition Expense Form

USAble Life Insurance – Group Enrollment or Change

USAble Life Insurance – Evidence of Insurability

USAble Voluntary Life Insurance


Income Tax Withholding – Federal – W4

Income Tax Withholding – State- AR4EC

Travel Reimbursement

Federal Per Diem Information
Mileage Form 2017
Travel Expense Form 2016
Per Diem Travel Advance Request

Forms for County Supervisors

Background Check Consent Form

Background Check Pre-Adverse Action Letter

Background Check Final Adverse Action Letter

Budget Worksheet – 2016

Employment Eligibility Verification – I-9

FMLA – Employer’s Response

Part-time/Extra Help – Approval over $10.50

Performance Evaluation – Annual

Performance Evaluation – Quarterly

Pulaski County Purchasing Policy

Job Evaluation – Existing Position Request

Job Evaluation- Job Analysis Questionnaire

Job Evaluation – New Position

Workers’ Compensation – First Report of Injury or Illness

Workers’ Compensation – Employee’s Notice of Injury

Workers’ Compensation – Supplemental Report

To report problems with the Email or Self Service System contact Information Systems at 340-8456 or contact webmaster@pulaskicounty.net