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.
In connection with this application, the undersigned hereby authorize and instructs Cornerstone Bank to:
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.
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.
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.
By typing my name, I confirm this statement.
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.
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.
[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.
*This information will be used for background screening purposes only and will not be used as hiring criteria.
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.
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:
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):
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.
The term "disability" means, with respect to the Americans with Disabilities Act refers to an individual who
(A) a physical or mental impairment that substantially limits one or more of the major life activities of such
(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.
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):
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 firstname.lastname@example.org.