________________________________________________________________ APPLICATION FOR EMPLOYMENT ---------------------------------------------------------------------- *Please read the following before filling out this application form. This bank is an equal opportunity employer and does not discriminate in recruiting, hiring, training, promoting or other employment practices for reasons of race; color; religion; sex; national origin; age; Veteran/Reserve, National Guard status, or disability. No question in this application is intended to secure information to be used for such discrimination. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. The bank at its own expense, arranges for a surety bond for each of its employees. Unless the applicant's bankground is acceptable to a surety company, it will be difficult to secure this bond and the bank may be unable to offer employment. Please complete this form carefully in your own handwriting. Replies to all questions will be held in strictest confidence. _______________________________________________________________________ Last Name First Middle SS# _______________________________________________________________________ Phone# Present Address City State Zip _______________________________________________________________________ | |From |To |____________________________________________|_______|________ Addresses| | | for |____________________________________________|_______|________ Last Five| | | years |____________________________________________|_______|________ | | | |____________________________________________|_______|________ | | | _________|____________________________________________|_______|________ Are you legally eligible to be employed in the United States? [ ] Yes [ ] No Can you provide proof? [ ] Yes [ ] No _______________________________________________________________________ Are you 18 years or older? [ ] Yes [ ] No _______________________________________________________________________ If needed, do you have the proper work permits? [ ] Yes [ ] No [ ] N/A _______________________________________________________________________ Position desired: [ ] Full Time [ ] Part Time How soon could you report to work? Rate of Pay Expected: _______________________________________________________________________ How did you come to apply? [ ] Employee Referral [ ] High School Recruitment [ ] Newspaper Ad [ ] Former Employee [ ] College Recruitment [ ] Walk-In [ ] Employment Agency [ ] Other: _______________________________________________________________________ Have you ever been convicted of a criminal offense, specifically involving dishonesty or breach of trust (including but not limited to robbery, embezzlement, forgery, perjury, tax evasion, etc.)? [ ] Yes [ ] No If so, state dates, place, courts, where offense occurred and judgment given: _______________________________________________________________________ GIVE PERSONAL REFERENCES WHO ARE NOT RELATIVES OR FORMER EMPLOYERS _______________________________________________________________________ NAME ADDRESS OCCUPATION YEARS KNOWN _______________________________________________________________________ | | | ________________|___________________________|______________|___________ | | | ________________|___________________________|______________|___________ | | | ________________|___________________________|______________|___________ WE ARE AN EQUAL OPPORTUNITY EMPLOYER _______________________________________________________________________ SHOW PRESENT AND PAST EMPLOYMENT FOR PAST FIVE YEARS INCLUDING PART TIME EMPLOYMENT _______________________________________________________________________ Employment Dates|Employment |Salary Month/Year | |Start |Final ________________|___________________________________|_________|________ From: |Co. Name |$ |$ |___________________________________| | ----------------|Address | | To: |___________________________________| | |City State Zip |Per: |Per: ________________|___________________________________|_________|________ |Type of Business |Title or |Describe Type of | |Position |Work Done |-----------------------|-----------|------------------ | | | | | | |_______________________|___________|__________________ |Reason for leaving above position ________________|______________________________________________________ Employment Dates|Employment |Salary Month/Year | |Start |Final ________________|___________________________________|_________|________ From: |Co. Name |$ |$ |___________________________________| | ----------------|Address | | To: |___________________________________| | |City State Zip |Per: |Per: ________________|___________________________________|_________|________ |Type of Business |Title or |Describe Type of | |Position |Work Done |-----------------------|-----------|------------------ | | | | | | |_______________________|___________|__________________ |Reason for leaving above position ________________|______________________________________________________ Employment Dates|Employment |Salary Month/Year | |Start |Final ________________|___________________________________|_________|________ From: |Co. Name |$ |$ |___________________________________| | ----------------|Address | | To: |___________________________________| | |City State Zip |Per: |Per: ________________|___________________________________|_________|________ |Type of Business |Title or |Describe Type of | |Position |Work Done |-----------------------|-----------|------------------ | | | | | | |_______________________|___________|__________________ |Reason for leaving above position ________________|______________________________________________________ Employment Dates|Employment |Salary Month/Year | |Start |Final ________________|___________________________________|_________|________ From: |Co. Name |$ |$ |___________________________________| | ----------------|Address | | To: |___________________________________| | |City State Zip |Per: |Per: ________________|___________________________________|_________|________ |Type of Business |Title or |Describe Type of | |Position |Work Done |-----------------------|-----------|------------------ | | | | | | |_______________________|___________|__________________ |Reason for leaving above position ________________|______________________________________________________ Employment Dates|Employment |Salary Month/Year | |Start |Final ________________|___________________________________|_________|________ From: |Co. Name |$ |$ |___________________________________| | ----------------|Address | | To: |___________________________________| | |City State Zip |Per: |Per: ________________|___________________________________|_________|________ |Type of Business |Title or |Describe Type of | |Position |Work Done |-----------------------|-----------|------------------ | | | | | | |_______________________|___________|__________________ |Reason for leaving above position ________________|______________________________________________________ _______________________________________________________________________ Have you been employed here before? [ ] Yes [ ] No Have you applied here before? [ ] Yes [ ] No _______________________________________________________________________ Have you ever been discharged or requested to resign from a position? [ ] Yes [ ] No If so explain: _______________________________________________________________________ May we contact your present or previous employer(s)? [ ] Yes [ ] No _______________________________________________________________________ Give Employment References: _______________________________________________________________________ SUPERVISORS NAME |COMPANY & ADDRESS |PHONE |YEARS & TITLE | | |KNOWN _____________________|___________________________|_______________|_____ | | | _____________________|___________________________|_______________|_____ | | | _____________________|___________________________|_______________|_____ | | | _____________________|___________________________|_______________|_____ Why do you desire to make a change? Have you ever held a position of trust (handling money or confidential material)? [ ] Yes [ ] No _______________________________________________________________________ NAME & LOCATION |Grad |Diploma|Major/| GPA List any special schooling (ext, night, etc) | |Degree | Minor| _____________________________________________|_____|_______|______|____ GRADE SCHOOL | | NA | NA | NA | ______________|______________________________|_____|_______|______|____ HIGH SCHOOL | | | | NA | ______________|______________________________|_____|_______|______|____ COLLEGE | | | | | ______________|______________________________|_____|_______|______|____ OTHER(AIB,etc)| | | | | ______________|______________________________|_____|_______|______|____ _______________________________________________________________________ Check the appropriate space below to show experience or training in the skills or equipment named. Also name and briefly describe courses taken in school, present or past positions, or other experience that will especially fit you for the position for which you apply. [ ] BOOKKEEPING [ ] ADDING MACHINE [ ] ACCOUNTING [ ] CREDIT INVESTIGATON [ ] KEY PUNCH MACHINE [ ] TYPING _____WPM [ ] PROOF MACHINE [ ] COMPUTER OPERATOR [ ] DICTATING EQUIPMNT Model____________ Model____________ [ ] TABULATING EQUIPMENT[ ] CRT OPERATOR [ ] SHORTHAND _____WPM [ ] WORD PROCESSING [ ] OTHER (List those skills or abilities which you consider relevant to this job) _______________________________________________________________________ ACTIVITIES (Only activities you consider relevant to your ability to perform this job should be listed) List only those activities, such as civic, athletic, fraternal, etc., which you consider relevant to this job: (Exclude organizations, the name or character of which indicates the race, creed, color, religion or national origin of it's members) _______________________________________________________________________ Have you ever served in the U.S. Armed Services? [ ] Yes [ ] No Date Entered Service: Date Discharged: If so, what branch or branches? _______________________________________________________________________ _______________________________________________________________________ (A) I hereby agree to being fingerprinted before or during my employment and agree to my fingerprint record being processed by the FBI. (B) I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. (C) I fully understand because of the nature of the business conducted by the bank that all information, whether written, spoken or otherwise communicated or obtained, and all files and records of any and every description relating to the business of the bank or to anyone with whom the bank has dealings, constitute privileged matters and are to be treated in a strictly confidential manner. I fully understand and agree that, should I enter employment of the bank, I am not to, and will not at anytime, communicate or reveal any business of the bank or any such information or records or files or the matters contained therein to unauthorized personnel within the bank, or to any- one outside the bank. I also understand that any violation of the foregoing shall be sufficient grounds for termination of my employment. (D) In the event I am employed by the bank, I will comply with all rules and regulations as set forth in the bank's policy manual or other communications distributed to all employees. (E) I understand that if I am hired, my continued employment may be conditioned upon a health evaluation which may include a physical examination by a doctor selected by the bank to which I hereby consent. This health evaluation will also include a chemical analysis to determine whether I am a user or addicted to illegal drugs and/or alcohol, to which I also consent. (F) I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. (G) I understand that I may be asked to voluntarily submit to a poly- graph examination as part of an on-going investigation if the employer has sustained an economic loss or injury as a result of actions such as theft or embezzlement. (H) I understand that if I am employed, a photograph may be later required. (I)I authorize a Consumer Investigative Report which will provide applicable information on my credit status, personal character, employment and public records. If the bank denies employment either in whole or in part because of any information contained in the report, the reason will be communicated to me as required by the Fair Credit Reporting Act. (J) I understand that the bank employs only U.S. citizens and properly authorized aliens. If I become employed, federal law requires that I furnish to the bank proof of my identity and employment authorization and to sign a statement under penalty of perjury verifying my eligibility for employment as a citizen or national of the United States or an otherwise employable alien. (K) I hereby acknowledge that I have read the above statement and understand the same. ____________________ ________________________________ Application Date Applicant's Signature (This is to advise you that your application for employment will be processed as quickly as possible. Public Law 91-508 requires that we advise you that a routine inquiry may be made during our initial or subsequent processing which will provide applicable information concerning character and general reputation for honesty and truth- fulness. Upon written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided.) THIS APPLICATION VOID AFTER 90 DAYS, UNLESS RENEWED BY THE APPLICANT. _______________________________________________________________________