Application for Employment

"Equal Opportunity Employer"

Personal Information

Last Name First Name Middle Initial Social Security Number Primary Phone Number Alternate Phone Number

Present Address

Mailing Address City State Zip Code

Is your present address your permanent address? Yes No

Permanent Address

Mailing Address City State Zip Code

Personal Status

Are you 18 years of older? Yes No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Yes No

Have you ever been convicted of a crime or traffic violation? Yes No

If Yes, explain

Employment Desired

Position Salary Desired

Full-Time or Part-Time? Full-Time Part-Time

Date You Can Start

Are you employed now? Yes No

If so, may we inquire of your present employer? Yes No

Name of Supervisor Phone Number

Ever applied to this company before? Yes No

Where When Referred By

Education

Have you graduated from high school or passed the GED? Yes No

List the high school, college, business school, military training, and other relevant education.

Education

School Name and Location Years Attended Did you graduate? GPA Subjects Studied or Degree Obtained

General

List Any Computer or Office Skills Other Special Skills Activities (Civic, Athletic, etc.) Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members.

U.S. Military or Naval Service Yes No

Rank Present Membmership in National Guard or Reserves

Former Employers

List below last three employers, last one first.

Employer

Name and Address of Employer From (Date, Month and Year) To (Date, Month and Year) Salary Position Reason for Leaving

Which of these jobs did you like the best? What did you like most about this job?

References

Give the names of three persons not related to you, whom you have known at least one year.

Reference

Name Phone Number Years Acquainted Address

In Case of Emergency Notify

Name Phone Number Address

Agreement

By typing my name below and clicking the submit button, I certify that all the information submitted by me on this application is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations. I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I also understand that unless specifically asked not to, references will be checked. If this application is created as or converted into an electronic application, I consent to the use of electronic records and signatures as defined by the federal and/or state electronic transaction laws. I agree if the application is delivered to the financial institution as an electronic record or facsimile transmission with my electronic signature, it will be as effective, enforceable and valid as if a paper version of the application were delivered and signed by me in writing.

Signature Date