Name:
Date

 

Office Use Only Date
Application #  

Application For Employment


Employment Information

Cornerstone Bank hereinafter referred to as the "Bank" appreciates your interest. The Bank provides all employees and applicants equal opportunity for employment without regard to race, color, sex, age, religion, national origin, marital status, and to disabled veterans, veterans of the Vietnam era, other covered veterans, and individuals with a disability, and any other characteristics protected by Federal, State or Local law.

The Bank, at its own expense, arranges for a surety bond for each of its employees. Unless the applicant's background is acceptable to a surety company (not relative to race, color, sex, age, disability, religious creed, national origin, ancestry, marital status or veteran status), it will be difficult to secure this bond and the Bank may be unable to offer employment.

Authorization for Consumer Credit Reports and Investigative Consumer Reports

In connection with this application, the undersigned hereby authorize and instructs Cornerstone Bank to:

  1. make such inquiries and investigations as may be deemed necessary or appropriate;
  2. contact, question and interview persons who are not consumer reporting agencies;
  3. secure consumer reports or investigative consumer reports.

I authorize and instruct any and all persons, consumer reporting agencies and other parties to make such inquires as may be appropriate and to compile and furnish such information to the Bank in connection with this application for employment.


Accept   Decline

 


 

Information on this application is strictly confidential. In addition to enabling us to evaluate you as a prospective employee, it will also serve as a permanent record should you be employed by the Bank. THE APPLICATION MUST BE COMPLETED IN FULL.

Personal Data


Legal Name: (First, Middle, Last)
Social Security No.
- -
 
Present Address:
 
City
State
Zip
       
Length of time at this address:  months
 
years
List previous addresses for which you have resided in the last 5 years within the United States:

       
Home Phone:
- -
Work Phone:
- -
       
Mobile/Beeper/Other Phone:
- -
Email Address:
       
How were you referred to us? Please include name of source.
Advertisement
Walk - in
Employee
Employment Agency
Relative
Other
       
Are you under the age of 16? Yes No
       
Are you legally eligible for employment in the United States? Yes No
(Proof of citizenship or immigration status will be required upon employment)
       
Do you have any friends or relatives working at this bank? Yes No
If yes, list the name(s) and relationship:
       
Have Cornerstone Bank or its affiliates employed you previously? Yes No
If yes, at what location and approximate date?
       
Have you ever been bonded? Yes  No    If yes, When?
For what position?
       
Have you ever been refused bonding? Yes  No   
If yes, please explain

       
Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation? Yes  No   
If yes, state offense(s), date(s), and location(s):

       
Have you worked or attended school under another name? Yes  No   
If yes, provide other name(s)


General Position Information



Position desired: 1st Choice
2nd Choice
     
Do you want to work: Full-time Part-time
     
Date available to work? / /    Desired salary $ per
     
Hours of the day available to work:
  EXAMPLE Monday Tuesday Wednesday Thursday Friday Saturday/Sunday
A.M. 7:00
P.M. 6:30
Use the space below to describe the skills and personal attributes that you feel qualify you for a position with our bank.
Please tell why you are interested in being employed with the bank.



Education and Training

EDUCATION
TYPE OF SCHOOL
NAME AND ADDRESS OF SCHOOL DEGREE SELECT LAST
YEAR
ATTENDED
MAJOR
High School
10
11  12
College
1   2
3   4
College
1   2
3   4
Graduate School
1   2
3   4
Other
1   2
3   4
Indicate any extracurricular activities in which you participated and any awards or special recognition you may have received during school or since leaving school that you feel would be relevant to the position you are applying.


Employment History

List below all present and past employment, beginning with your most recent employment, for the last 10 years or years worked if less than 10 years.
(Include self-employment, summer, and part-time employment.)

Company Name and Address:   Phone: - -
Job Title: Description of duties:


Reason for leaving:
From Month
Year
Hourly Rate/Salary
Start $ per
Final $ per
To Month
Year
May we contact this employer?  Yes  No  Later
Supervisor's Name/Title:
Company Name and Address:   Phone: - -
Job Title: Description of duties:

Reason for leaving:
From Month
Year
Hourly Rate/Salary
Start $ per
Final $ per
To Month
Year
May we contact this employer?  Yes  No  Later
Supervisor's Name/Title:
Company Name and Address:   Phone: - -
Job Title: Description of duties:

Reason for leaving:
From Month
Year
Hourly Rate/Salary
Start $ per
Final $ per
To Month
Year
May we contact this employer?  Yes  No  Later
Supervisor's Name/Title:
Company Name and Address:   Phone: - -
Job Title: Description of duties:

Reason for leaving:
From Month
Year
Hourly Rate/Salary
Start $ per
Final $ per
To Month
Year
May we contact this employer?  Yes  No  Later
Supervisor's Name/Title:
Company Name and Address:   Phone: - -
Job Title: Description of duties:

Reason for leaving:
From Month
Year
Hourly Rate/Salary
Start $ per
Final $ per
To Month
Year
May we contact this employer?  Yes  No  Later
Supervisor's Name/Title:
Company Name and Address:   Phone: - -
Job Title: Description of duties:

Reason for leaving:
From Month
Year
Hourly Rate/Salary
Start $ per
Final $ per
To Month
Year
May we contact this employer?  Yes  No  Later
Supervisor's Name/Title:

List any other experience, skills or other qualifications, including hobbies, which you believe should be considered in evaluating your qualifications for employment. Please indicate any prior military service that you would like considered in connection with your application for employment.



PLEASE READ THE FOLLOWING CONDITIONS OF EMPLOYMENT AND CERTIFY BY YOUR SIGNATURE THAT YOU UNDERSTAND AND AGREE TO THESE CONDITIONS.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to the Human Resources Department before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation. If hired, I agree to abide by all of the company policies, rules and regulations, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the Bank or me. It is my understanding that I could be subject to a polygraph test while employed by the Bank.

I further understand that no representation, whether oral or written by any representative or agent of the Bank, at any time, can constitute a contract of employment. I understand that the Bank and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment.

No representative or agent of the Bank has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President of Cornerstone Bank, or to make any agreement contrary to the foregoing.

The application is current for 60 days from the date signed. At the conclusion of the 60 days, if I wish to continue to be considered for employment, it will be necessary for me to complete a new application form.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.

Signature of Applicant
Date

By typing my name, I confirm this statement.


Supplemental Skills


 

Name
Date

Please read the following evaluation scale carefully and enter the most appropriate number in the spaces provided next to each skill/task. Incomplete or incorrectly completed supplements will not be considered.

3 = Extensive Skill and Experience: Have performed task extensively in a work setting. No training required.
2 = Moderate Skill: Have performed this function and/or used this skill. Limited orientation needed.
1 = Minimal Skill: Intermittent /occasional use or classroom training only.
0 = Unskilled: if you have no experience or have never performed task.


Clerical Banking
Contracts Back Counter/Image
Correspondence Loan Administration
Editing for Spelling, Grammar & Punctuation Loans
Forms Teller Machine
Reports  
Statistical Data Scheduling / Coordination
Distribute / Route / Post Mail Appointment Calendar
Fax Machine Operations Conferences / Seminars
Taking Meeting Minutes Meetings
   
Computer Software Budget Control
Microsoft Office Develop Proposal
Microsoft Exel Expense Report Preparation
Microsoft Word Monitor Expenditures
Microsoft Publisher  
PowerPoint Accounting / Bookkeeping
MS Outlook 10-Key Calculator
NT System Accounts Payable
Laser Pro Accounts Receivable
Fiserv Software Billing
Other (please specify): Cash Handling
Other (please specify): Computerized Financial Systems
Other (please specify): General Ledgers
  Payment Scheduling
Computer Tasks Payroll
Charts/Graphs Posting
Creating Macros Reconciliation
Data Entry Transfer of Funds
Graphics  
Labels Supervision
Merges Employees – How Many
Newsletter Evaluate Job Performance
Scanning/Indexing Interview & Select
Spreadsheets Review Work
Tables Schedule Work
Templates Take Corrective Action
Web Design Train Staff
   
Customer Service / Public Contact  
Assist Public / Customers  
Front Desk Reception  
Busy / Fast-Paced Traffic  
Slow / Moderate Traffic  
Problem Solving  
Multi-Line Telephone (4+ lines)  

Certification: I certify that all of the statements made are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that I may be expected to substantiate these self-ratings if invited to interview.

Name
Date

By typing my name, I confirm this statement.

Applicant Disclosure and Authorization Form

[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Cornerstone Bank ("The Company") may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history including current position, worker's compensation injuries, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by [One Source The Background Check Company, PO Box 24148 Omaha, NE 68124, 1.800.608.3645] or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Cornerstone Bank to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by [One Source The Background Check Company, PO Box 24148 Omaha, NE 68124, 1.800.608.3645], another outside organization acting on behalf of Cornerstone Bank, and/or Cornerstone Bank itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

Last Name First Middle
Other Names/Alias
Social Security* # - - Date of Birth* / /
Driver's License # State of Driver's License
Present Address:
Phone Number
City State Zip
All Previous Addresses in the Last Seven Years

Signature
Date

By typing my name, I confirm this statement.

*This information will be used for background screening purposes only and will not be used as hiring criteria.

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: (a) a person has taken adverse action against you because of information in your credit report; (b) you are the victim of identity theft and place a fraud alert in your file; (c) your file contains inaccurate information as a result of fraud; (d) you are on public assistance; (e) you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
  • You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567¬-8688.
  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
  • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.

For information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau:
a. Bureau of Consumer Financial Protection
1700 G Street NW
Washington, DC 20552

b. Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580
2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480

c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106

d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Ave, Washington, DC 20590
4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board
Department of Transportation
395 E Street SW, Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access
United States Small Business Administration
406 Third Street, SW, 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F St NE
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580
(877) 382-4357

Invitation to Self-Identify


Name:


Social Security Number:
- -

Date:


It is the policy of the company to take affirmative action to seek to employ and advance in employment qualified individuals with disabilities, disabled veterans, veterans of the Vietnam, armed forces service medal veterans, recently separated veterans, and other protected veterans.

If you have a disability or are a veteran of the Vietnam era, a disabled veteran, armed forces service medal veteran, a recently separated veteran, or other protected veteran (see attachment for definitions); we would like to include you under our affirmative action program. If you would like to be included under the affirmative action program, please tell us. You may inform us of your desire to benefit under the program at this time and/or at any time in the future. Submission of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended and with section 503 of the Rehabilitation Act.

Please check ALL of the following as it applies to you (see below for Definitions):


Person with a Disability Armed Service Medal Veteran
Vietnam Era Veteran Other Protected Veteran
Disabled Veteran Recently Separated Veteran
        (date of discharge: )

If you are an individual with a disability or a disabled veteran, it would assist us if you tell us about (i) any special methods, skills, and procedures which qualify you for positions that you might not otherwise be able to do because of your disability so that you will be considered for any positions of that kind, and (ii) the accommodations which we could make which would enable you to perform the job properly and safely, including special equipment, changes in the physical layout of the job, elimination of certain duties relating to the job, provision of personal assistance services or other accommodations. This information will assist us in placing you in an appropriate position and in making accommodations for your disability.



Definitions

The term "disability" means, with respect to the Americans with Disabilities Act refers to an individual who has:

(A) a physical or mental impairment that substantially limits one or more of the major life activities of such individual;
(B) a record of such an impairment; or
(C) being regarded as having such an impairment.

Vietnam era veteran refers to a person who served on active duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any part of such active duty occurred in the Republic of Vietnam between February 28, 1961, and May 7, 1975 or between August 5, 1964, and May 7, 1975, in all other cases. The term also refers to a person who was discharged or released from active duty for a service connected disability if any part of such active duty was performed in the Republic of Vietnam between February 28, 1961, and Mary 7, 1975, or between August 5, 1964, and May 7, 1975, in all other cases.

Disabled veteran refers to a 1) 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, or 2) 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 such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.

An armed service medal veteran refers to any veteran who, while service 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 12985.

Other protected veteran refers to any veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

Recently separated veteran refers to any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty.

 

Race & Ethnicity

 

Name:
 
Position applied for:
 
Date:


The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Race/Ethnicity (Please check all that apply):

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
 
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
 
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
 
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
 
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
 
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
 

Sex

Male Female



If you would like a copy of this completed application, please print this page before clicking submit.

   

If you would like to submit a resume in addition to your application, please e-mail it to hr@cornerstoneconnect.com.