AT WILL EMPLOYMENT APPLICATION
(Void after 90 days)
First State Bank is an Equal Opportunity Employer of women, minorities, protected veterans and individuals with disabilities.
The company does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability or genetic information, veteran status, sexual orientation, gender identity or any other characteristic protected by law.
PERSONAL
Last Name
First
Middle
Date
Email Address
Home Telephone
Street Address
Business Telephone
City
State
ZIP
Cell Phone
Location(s) Preferred:    
St. Charles, MO Lake Ozark, MO  
O'Fallon, MO Lee's Summit, MO  
Lake St. Louis, MO Overland Park, KS  
Chesterfield, MO    
Position Desired
Full Time
Part Time
Pay Expected
Name of Referral Source
Seasonal
Ed/Co-op
Will you work overtime if asked?
Yes          No
Are you currently authorized to be employed in the U.S. on a full-time basis?
Yes          No
When will you be available to begin work?
If you are selected for hire, you will be required to provide documentary evidence of your identity and eligibility to work in the United States.
NOTICE: First State Bank does conduct a pre-employment drug screening, criminal and background investigation.
Are you over 18 years of age?
Yes          No
EDUCATION
School Name and Location of School Course of Study No. of Years Completed Did you
Graduate?
Degree or
Diploma & GPA

Graduate Yes
No
College Yes
No
Business/Trade/
Technical
Yes
No
High School Yes
No
Do you intend to continue your education?       Yes          No  
If yes, When and where?
EMPLOYMENT RECORD
List last four (4) employers, starting with present or most recent. Please fully complete and do not use the term "See Resume."
1. Employer
Dates Employed
Address
From
To
Telephone Number(s)
Job Title
Supervisor
Hourly Rate/Salary
Reason for Leaving
Starting
Final
Work Performed
     

   

2. Employer
Dates Employed
Address
From
To
Telephone Number(s)
Job Title
Supervisor
Hourly Rate/Salary
Reason for Leaving
Starting
Final
Work Performed

3. Employer
Dates Employed
Address
From
To
Telephone Number(s)
Job Title
Supervisor
Hourly Rate/Salary
Reason for Leaving
Starting
Final
Work Performed

4. Employer
Dates Employed
Address
From
To
Telephone Number(s)
Job Title
Supervisor
Hourly Rate/Salary
Reason for Leaving
Starting
Final
Work Performed

Are you currently employed? Yes          No
If yes, may we contact your employer? Yes          No
Which of your former jobs did you like best?  Why? 
Why do you wish to change your current employment?
Which business machines, computer equipment and software can you operate proficiently?
Have you taken training courses with previous employers that would benefit you in this position? If yes, describe.
Membership in Professional or Civic Organization (exclude those which may disclose your race, color, religion or national origin).
GENERAL INFORMATION
Have you previously applied for employment with the Bank?      Yes      No
If yes, when?

Have you previously been employed at the Bank?      Yes      No
If yes, when?

Have you ever been bonded?      Yes      No
Have you ever been refused bond?      Yes      No
If yes, state the reason and date:
To your knowledge, is there any reason you would not be bondable?      Yes      No
If yes, explain:

Have you ever been convicted or plead guilty to a crime?      Yes      No
NOTE: Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
If yes, please identify the crime, conviction date, and place (jurisdiction), where the conviction was made:

Please include any other information you may think would be helpful in considering you for employment, including additional work experience, articles/books published, activities, accomplishments and so forth. Exclude all information indicative of age, sex, race, religion, color, national origin, and disability.

REFERENCES
Give the names of three persons not related to you, who are familiar with your work performance and have known you at least one (1) year. Include the name of at least one supervisor.
Name Address Phone Relationship

1) Supervisor
2)
3)
   
 
APPLICANT'S REPRESENTATIONS FOR EMPLOYMENT

Should I be employed by the Bank, I agree to conform to the Bank's rules and regulations, and agree that as an at will employee, my employment and compensation can be terminated, at any time, for any or no reason, with or without notice, at the option of either the Bank or myself.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering, and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentation are discovered, my application may be rejected or if employed, my employment may be terminated. I give you the right to investigate all statements above.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I understand that employees may be terminated with or without cause and with or without notice at any time. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, except as by required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration.

I understand that no manager or representative of the company, other than its president or his designee, has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing either now, in the past or in the future. I further understand that such an agreement must be in writing and signed by the president for it to be binding on either myself or the company. I further understand that this statement supersedes any prior oral or written understanding and bars any future oral understanding to the contrary.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 form in this regard.

I certify that I have read, fully understand, and accept all terms of the preceding applicant statement. By checking this box I agree to the above terms of employment.
Equal Employment Opportunity is THE LAW
Private Employers, State and Local Governments, Educational Institutions, Employment Agencies and Labor Organizations
Applicants to and employees of most private employers, state and local governments, educational institutions, employment agencies and labor organizations are protected under Federal law from discrimination on the following bases:
RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN
Title VII of the Civil Rights Act of 1964, as amended, protects applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy), or national origin. Religious discrimination includes failing to reasonably accommodate an employee’s religious practices where the accommodation does not impose undue hardship.

DISABILITY
Title I and Title V of the Americans with Disabilities Act of 1990, as amended, protect qualified individuals from discrimination on the basis of disability in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. Disability discrimination includes not making reasonable accommodation to the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or employee, barring undue hardship.
GENETICS
Title II of the Genetic Information Nondiscrimination Act of 2008 protects applicants and employees from discrimination based on genetic information in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. GINA also restricts employers’ acquisition of genetic information and strictly limits disclosure of genetic information. Genetic information includes information about genetic tests of applicants, employees, or their family members; the manifestation of diseases or disorders in family members (family medical history); and requests for or receipt of genetic services by applicants, employees, or their family members.

RETALIATION
All of these Federal laws prohibit covered entities from retaliating against a person who files a charge of discrimination, participates in a discrimination proceeding, or otherwise opposes an unlawful employment practice.
AGE
The Age Discrimination in Employment Act of 1967, as amended, protects applicants and employees 40 years of age or older from discrimination based on age in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment.

SEX (WAGES)
In addition to sex discrimination prohibited by Title VII of the Civil Rights Act, as amended, the Equal Pay Act of 1963, as amended, prohibits sex discrimination in the payment of wages to women and men performing substantially equal work, in jobs that require equal skill, effort, and responsibility, under similar working conditions, in the same establishment.
WHAT TO DO IF YOU BELIEVE DISCRIMINATION HAS OCCURRED
There are strict time limits for filing charges of employment discrimination. To preserve the ability of EEOC to act on your behalf and to protect your right to file a private lawsuit, should you ultimately need to, you should contact EEOC promptly when discrimination is suspected: The U.S. Equal Employment Opportunity Commission (EEOC), 1-800-669-4000 (toll-free) or 1-800-669-6820 (toll-free TTY number for individuals with hearing impairments). EEOC field office information is available at www.eeoc.gov or in most telephone directories in the U.S. Government or Federal Government section. Additional information about EEOC, including information about charge filing, is available at www.eeoc.gov.
Employers Holding Federal Contracts or Subcontracts
Applicants to and employees of companies with a Federal government contract or subcontract are protected under Federal law from discrimination on the following bases:
RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN
Executive Order 11246, as amended, prohibits job discrimination on the basis of race, color, religion, sex or national origin, and requires affirmative action to ensure equality of opportunity in all aspects of employment.





INDIVIDUALS WITH DISABILITIES
Section 503 of the Rehabilitation Act of 1973, as amended, protects qualified individuals from discrimination on the basis of disability in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. Disability discrimination includes not making reasonable accommodation to the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or employee, barring undue hardship. Section 503 also requires that Federal contractors take affirmative action to employ and advance in employment qualified individuals with disabilities at all levels of employment, including the executive level.
DISABLED, RECENTLY SEPARATED, OTHER PROTECTED, AND ARMED FORCES SERVICE MEDAL VETERANS
The Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212, prohibits job discrimination and requires affirmative action to employ and advance in employment disabled veterans, recently separated veterans (within three years of discharge or release from active duty), other protected veterans (veterans who served during a war or in a campaign or expedition for which a campaign badge has been authorized), and Armed Forces service medal veterans (veterans who, while on active duty, participated in a U.S. military operation for which an Armed Forces service medal was awarded).

RETALIATION
Retaliation is prohibited against a person who files a complaint of discrimination, participates in an OFCCP proceeding, or otherwise opposes discrimination under these Federal laws. Any person who believes a contractor has violated its nondiscrimination or affirmative action obligations under the authorities above should contact immediately: The Office of Federal Contract Compliance Programs (OFCCP), U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210, 1-800-397-6251 (toll-free) or (202) 693-1337 (TTY). OFCCP may also be contacted by e-mail at OFCCP-Public@dol.gov, or by calling an OFCCP regional or district office, listed in most telephone directories under U.S. Government, Department of Labor.
Programs or Activities Receiving Federal Financial Assistance
RACE, COLOR, NATIONAL ORIGIN, SEX
In addition to the protections of Title VII of the Civil Rights Act of 1964, as Section 504 of the Rehabilitation Act of 1973, as amended, prohibits employment amended, Title VI of the Civil Rights Act of 1964, as amended, prohibits discrimination on the basis of disability in any program or activity which receives discrimination on the basis of race, color or national origin in programs or Federal financial assistance. Discrimination is prohibited in all aspects of activities receiving Federal financial assistance. Employment discrimination employment against persons with disabilities who, with or without reasonable is covered by Title VI if the primary objective of the financial assistance is accommodation, can perform the essential functions of the job. provision of employment, or where employment discrimination causes or may If you believe you have been discriminated against in a program of any cause discrimination in providing services under such programs. Title IX of the institution which receives Federal financial assistance, you should immediately Education Amendments of 1972 prohibits employment discrimination on the contact the Federal agency providing such assistance. basis of sex in educational programs or activities which receive Federal financial assistance
INDIVIDUALS WITH DISABILITIES
Section 504 of the Rehabilitation Act of 1973, as amended, prohibits employment discrimination on the basis of disability in any program or activity which receives Federal financial assistance. Discrimination is prohibited in all aspects of employment against persons with disabilities who, with or without reasonable accommodation, can perform the essential functions of the job.

If you believe you have been discriminated against in a program of any institution which receives Federal financial assistance, you should immediately contact the Federal agency providing such assistance.
EEOC 9/02 and OFCCP 8/08 Versions Useable With 11/09 Supplement EEOC-P/E-1 (Revised 11/09)
First State Bank
has a Drug Free
Work Environment
in all bank buildings
and on the premises
Thank you for your cooperation
First State Bank
Voluntary Affirmative Action
Self Identification Data Record - Race/Ethnicity and Gender
 
We are an Equal Opportunity Employer, which means that we operate in strict compliance with all applicable laws prohibiting discrimination or harassment on the basis of race, color, religion, national origin, sex, age, marital status, height, weight, qualified disabled status, U.S. military veteran status or personal characteristics covered by applicable civil rights laws, regulations and orders.

As an employer with an Affirmative Action Program, we also comply with government regulations, including Affirmative Action responsibilities where they apply.

The process for this Voluntary Affirmative Action Self Identification Data Record is to assist us to comply with government record keeping, reporting, and other legal requirements. THE COMPLETION OF THIS SELF INDENTIFICATION DATA RECORD IS OPTIONAL. IF YOU CHOOSE TO VOLUNTEER THE REQUESTED INFORMATION PLEASE NOTE THAT IT WILL BE USED ONLY TO ASSIST US IN OUR AFFIRMATIVE ACTION RECORDKEEPING, AND WILL BE KEPT IN A CONFIDENTIAL FILE, AND NOT AS PART OF YOUR APPLICATION FOR EMPLOYMENT OR PERSONNEL FILE. PLEASE NOTE: YOUR COOPERATION IS VOLUNTARY; INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.
Last Name
First Name
Middle Name
Street Address
City
State
   
ZIP
Telephone Number(s)
   
Position Applied For:
I am a protected veteran
Yes No
Gender (check one):     Male     Female
 
Ethnicity / Race (check one - description of categories below):
Hispanic or Latino Ethnicity
White (not Hispanic or Latino)
American Indian / Alaskan Native (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)
Two or more races (not Hispanic or Latino)
Equal Opportunity Employer
Description of Ethnicity / Race Categories
 
Hispanic or Latino Ethnicity- 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.

American Indian or Alaskan 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.

Black or African-American (Not Hispanic or Latino)- A person having origins in any of the black racial groups of Africa.

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.

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.

Two or More Races (Not Hispanic or Latino)- All persons who identify with more than one of the above five races.

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to hire, and provide equal opportunity to qualified people with disabilitiesi. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disablity?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disablibities include, but are not limited to:

• Blindness • Autism • Bipolar disorder • Post-traumatic stress disorder (PTSD)
• Deafness • Cerebral palsy • Major depression • Obsessive compulsive disorder
• Cancer • HIV/AIDS • Multiple sclerosis (MS) • Impairments requiring the use of a wheelchair
• Diabetes • Schizophrenia • Missings limbs or partially missing limbs • Intellectual disablity (previously called mental retardation)
• Epilepsy • Muscular dystrophy    

Please check one of the boxes below:

   YES I HAVE A DISABILITY (or previously had a disablity)
   NO I DON'T HAVE A DISABLITY
   I DON'T WISH TO ANSWER

   

Your Name

Today's date


Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.


iSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.