Employment Application

Applicant

First Name Middle Initial Last Name Maiden/Previous Name Suffix Social Security Number Birth Date Mother's Maiden Name Home Address City State Zip Code

Have you lived here for two or more years? Yes No

Previous Home Address City State Zip Code

Daytime Phone Number Home Phone Number E-mail Address Please do NOT email me important news and updates.

How would you prefer to be contacted? Home Phone Daytime Phone Email Other

Other Preference Referred By

Are you under 18 years of age? Work permit is needed if under 18. Yes No

Are you fluent in any language(s) other than English? Yes No

What other languages do you speak?

Job Specific Information

Position Applying For

What is your employment preference? Any Full-Time Part-Time Peak-Time

Temporary or Seasonal employment Desired Pay Rate Rate Per (Hour, Month, or Year) Date Available to Begin Work

What days/hours are you able to work?

Day	Start (AM)	End (PM)
Sunday	Sunday from	Sunday to
Monday	Monday from	Monday to
Tuesday	Tuesday from	Tuesday to
Wednesday	Wednesday from	Wednesday to
Thursday	Thursday from	Thursday to
Friday	Friday from	Friday to
Saturday	Saturday from	Saturday to

Are you willing to work overtime if requested to do so? Yes No

Are you an experienced operator of any of the following? (Select all that apply) Calculator Cash Advance Machine Cash Drawer Check Encoder Coin Machine Fax Machine Multi-line Switchboard PC Printer Other

If other please explain List any personal characteristics, skills, attitudes, or achievements which you feel would qualify you for this position.

Have you ever been convicted of a felony or misdemeanor, or do you have any charges pending against you? A conviction or pending charge will not be an automatic bar to employment and will be considered only as it relates to the job in question. Yes No

Have you been employed before? Yes No

Starting with the present or most recent, list all previous employers. Include self-employment, military service, summer and part-time jobs.

Employer

Employer Name Address City State Zip Code Last Position Held Employment Start Date Employment End Date (Today's date if current employer) Reason for Leaving Job Duties Name and Title of Supervisor Phone Number E-mail

May we contact this employer? Yes No

References

List the names of persons not related to you, who know of your work or qualifications.

Reference 1

First Name Last Name Phone Number

Reference 2

First Name Last Name Phone Number

Reference 3

First Name Last Name Phone Number

Endorsement

I certify that the facts set forth in this application are true, correct and complete without misrepresentations or omissions of any kind whatsoever. I authorize investigation of the statements I have made herein. I hereby release from any and all liability all representatives of First Missouri State Bank for their acts performed in connection with evaluating my application, background, credentials and qualifications. I hereby further authorize any party (including the companies, schools and organizations listed in this application form) to release any information they may have about me to First Missouri State Bank, including all of my personnel records with prior employers. I also release all persons, companies, schools and organizations (and all persons connected with them) who provide such information to First Missouri State Bank from any and all liability for any damage for giving this information. I understand that if any of the information on this application form is discovered to be incorrect, false or misleading or if there are any misrepresentations or omissions of and kind whatsoever, then First Missouri State Bank may deny me employment or terminate my employment, and I agree that First Missouri State Bank shall not be liable in any respect if it does so. I also understand that my employment at First Missouri State Bank is contingent upon the satisfactory completion of a drug screen and an investigation of my work record and references. I consent to a pre-employment physical examination and such future examinations as may be required by First Missouri State Bank, which may include drug screening. I understand that if I am employed by First Missouri State Bank, any such employment is not binding on either party for any specific period of time. I further understand that no representative of First Missouri State Bank, other than the CEO or President, has any authority to enter into any agreement for employment for any specified period of time. Any such agreement must be in writing and signed by such officer. I understand that any other written or oral statement to the contrary, even if made by a supervisor, manager or officer of First Missouri State Bank, is invalid and should not be relied on by me. I understand that if employed I will be an employee-at-will and that either First Missouri State Bank or I may terminate that employment relationship at any time, for any reason, with or without notice.

I acknowledge that I have read and understand the Employee Application Authorization. Applicant's Signature Date