Community State Bank is an equal opportunity employer dedicated to a policy of non-discrimination in all areas of employment. In accordance with this policy, all qualified applicants for employment will be considered without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, genetic information, disability, veteran status, or pregnancy, or any other status or condition protected by state law.

Application for Employment

Required Field

Date of Application Position Applying For

General Information

Social Security Number Last Name First Name Middle Telephone Number Present Address City State Zip Code Length of time at this address

Are you a U.S. citizen, an alien lawfully admitted to permanent residence, or an alien authorized to work in the United States? Yes No

Note: Federal law requires that you provide documents which verify your identity and your eligibility for employment in the U.S. As a condition of employment, you are required to provide such documentation and to sign a form establishing that you are lawfully able to work in the U.S.

Have you been employed here before? No Yes Date

Are you available to work? Full-time Part-time

Have you ever been convicted of a felony and / or larceny? Yes No

If yes, describe in full, including date(s)

Military Service

Were you ever in the U.S. Armed Forces? Yes No

If yes, please answer the following: Dates Served Branch of Service Describe service experience if related to position(s) for which you are applying

Education

High School

Name of Last High School Attended City State

Did you graduate? Yes No

College

Name of College Attended City State

Did you graduate? Yes No

Degrees, licenses or certificates earned Major Subject

 Add Another College

Additional Education and Skills

What other education or training have you had? Describe the type of training, the source and the dates. What job skills do you possess?

Employment History

Beginning with your present or last job, list below the four most recent positions you have held. Additional employers can be added below.

Employer

Employer Address Job Title Employment Start Date Employment End Date (Today's date if current employer) Supervisor Reason for Leaving Starting Hourly Rate / Salary Final Hourly Rate / Salary Work Performed

 Add Another Employer

References

Please list below three employment references whom we may contact for the purpose of obtaining information relating to your previous employment (or education, or personal references, if not employed).

Reference

Name / Position / Organization Address Telephone Number

 Add Another Reference

Authorization and Acknowledgment

I hereby certify that all answers given and statements made are true and correct. I hereby give Community State Bank the right to make a thorough investigation into my previous employment, education, and references. I hereby release all such persons from liability or damages incurred as a result of inquiry and furnishing this information. If hired, I understand that my employment is at will and constitutes no expressed or implied contract.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

Signature of Applicant Date

Job Applicant Self-Identification Form

We are a government contractor subject to all provisions of The Civil Rights Act of 1964, Executive Order 11246 (as amended), The Rehabilitation Act of 1973 (as amended), and The Vietnam Era Veterans' Readjustment Assistant Act of 1974 (as amended). Qualified applicants are considered without regard to race, color, age, sex, sexual orientation, gender identity, religion, national origin, genetic information, pregnancy, disability, or protected veteran status. In order to help us comply with government regulations, we would like you to answer the questions listed below. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. This form will be kept strictly confidential and separate from your Employment Application.

Date Last Name First Name Middle Initial

Gender: Please check one. Male Female

Race / Ethnicity: Please check one. Hispanic or Latino White (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) American Indian or Alaska Native (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino)

Are you a Protected Veteran? Please check one. Yes, I am a Protected Veteran.* No, I am not a Protected Veteran.

Disability Status: Please check one. Yes, I am an individual with a disability.** No, I do not have a disability.** I do not wish to answer.

* Protected Veteran Categories / Definitions

Disabled veteran:
- a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs for a disability, or
- a person who was discharged or released from active duty because of a service-connected disability
Recently separated veteran: any veteran during the three-year period beginning on the date of discharge or release from active duty in the U.S. military, ground, naval, or air service
Active duty wartime or campaign badge veteran: any veteran who served on active duty in the U.S. military, ground, naval, or air service during war or in a campaign or expedition for which a campaign badge has been authorized under laws administered by the Department of Defense
Armed Forces service medal veteran: any veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded, pursuant to Executive Order No. 12985

** Individual with Disability: any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities. (ii) has a record of such impairment; or (iii) is regarded as having such impairment

Referral

Position(s) applied for

Referral Source: Please check one. Walk-in Employee Advertisement Government Employment Agency Private Employment Agency School Relative Other

Name of person who referred you (if applicable)

Investigative Consumer Report Disclosure and Authorization

By this document, Community State Bank discloses to you that an investigative consumer report my be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment. This report may include information about your character, general reputation, personal characteristics, mode of living, criminal, driving, and work history, etc. This authorization shall remain on file if you are hired and shall serve as an ongoing authorization for Community State Bank to procure consumer reports at any time during your employment period. Community State Bank certifies that before taking any "adverse action" based in whole or in part on the report, which results in a denial of employment or any other decision for employment purposes that adversely affects any current or prospective employee, the Bank shall provide a copy of the report to the consumer as well as a written statement of the individual's rights under the law, as prescribed by the Federal Trade Commission.

I hereby authorize Community State Bank to obtain an Investigative Consumer Report and acknowledge receipt of the foregoing disclosure.

Signature of Applicant Date Verify your not a robot