Application for Employment

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex/gender, national origin, citizenship status, sexual orientation, disability, genetic information or past, current, or future service in the U.S. military, or any other legally protected status. The use of this form does not mean there are positions open and does not obligate the Bank in any way.

Personal Information

First Name Last Name Social Security Number Current Address City State Zip Code Phone Number E-mail Address Contact Name in Case of Emergency Phone Number

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

Previous Home Address City State Zip Code

Are you under 18 years of age? Yes No (Employment is subject to verification of minimum legal age.)

Can you produce documented proof of your identity and eligibility for employment in the United States? Yes No (Examples: driver's license, Social Security card, birth certificate, and/ or immigration documents)

Position(s) Applying For How soon could you report to work?

Type of employment desired Full-Time Part-Time Temporary

If part-time, what days/hours are you able to work?

Education

High School

Name Address City State Zip Code Courses Majored In Select Years Completed

Did you graduate? Yes No

Degree/Diploma

College

Name Address City State Zip Code Courses Majored In Select Years Completed

Did you graduate? Yes No

Degree/Diploma

Post Graduate

Name Address City State Zip Code Courses Majored In Select Years Completed

Did you graduate? Yes No

Degree/Diploma

Have you applied for a job with us before? Yes No

Have you ever worked for us before? Yes No

How did you come to apply? Employee Referral Former Employee Newspaper Ad High School Recruitment College Recruitment Walk-In Other

Which employee referred you? Please explain the other way you came to apply.

Have you ever been bonded? Yes No

Have you ever been refused a bond? Yes No

State Reason Date

Have you ever been convicted of or pled guilty to a violation of the law (excluding minor traffic violations)? Yes No

Court Nature of Offense Date (A conviction is not a bar to consideration for employment; facts & circumstances will be considered)

Have you ever been discharged or requested to resign from a position? Yes No

Please provide details

Have you ever held a position of trust (handling money or confidential material)? Yes No

Please provide details

Are you employed now? Yes No

May we contact your current employer? Yes No

Current Work Record

(Start with most recent or current employer and complete in full where applicable.)

Employer

Employer Name Address City State Zip Code Phone Number Immediate Supervior Name Immediate Supervior Position Employment Start Date Job Title Job Duties Reason for Leaving

Please provide any additional information such as special skills, training, experience, equipment operation, or other qualifications you feel will be helpful to us in considering your application.

Prior Work Record

(Start with most recent or current employer and complete in full where applicable.)

Employer

Employer Name Address City State Zip Code Phone Number Immediate Supervior Name Immediate Supervior Position Employment Start Date Employment End Date Job Title Job Duties Reason for Leaving

May we contact this employer? Yes No N/A - No prior employment

Please provide any additional information such as special skills, training, experience, equipment operation, or other qualifications you feel will be helpful to us in considering your application.

References

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

Reference 1

First Name Last Name Address City State Zip Phone Number Email

Reference 2

First Name Last Name Address City State Zip Phone Number Email

Job Applicant's Agreement and Certification

l certify that the information provided by me in this application is true in all respects, and I agree that if the information provided is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the bank and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the bank unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time, for any or no reason, and that the bank retains the same right.

I understand that if employed, policies, and rules which are issued are not contractual terms of employment and that the employer may revise policies or procedures in whole or in part, at any time.

I understand that this application will be kept on active file for up to 365 days from the date completed, after which time I would have to reapply in accordance with established company procedures.

Type Name to Agree

Completion of the following is voluntary

VOLUNTARY SELF-IDENTIFICATION OF RACE/ETHNICITY & SEX/GENDER

The Bank is required by law invite job applicants to voluntarily self-identify their race/ethnicity and sex/gender. Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department.

If you choose not to self-identify your race/ethnicity at this time, the federal government requires Hearthside Bank to determine this information by visual survey and/or other available information.

Sex/Gender: (Please check one of the options below) Male Female

Race/Ethnicity: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) 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 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. Native American 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 maintains tribal affiliation or community attachment. Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races. I do not wish to disclose.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

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. Disabilities include, but are not limited to:

Autism
Autoimmune disorder, for example, lupus, fibromyalgia,rheumatoid arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease

Cerebral palsy
Deaf or hard of hearing
Depression or anxiety
Diabetes
Epilepsy
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Intellectual disability

Missing limbs or partially
Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Please check one of the boxes below: Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability I Don’t Wish To Answer

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.

Voluntary Self-Identification of “Protected” Veteran Status

Why Are You Being Asked to Complete This Form?

This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA). VEVRAA requires Government contractors to take affirmative action to employ and advance in employment protected veterans. To help us measure the effectiveness of our outreach and recruitment efforts of veterans, we are asking you to tell us if you are a veteran covered by VEVRAA. Completing this form is completely voluntary, but we hope you fill it out. Any answer you give will be kept private and will not be used against you in any way.

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 .

How Do You Know if You Are a Veteran Protected by VEVRAA?

Contrary to the name, VEVRAA does not just cover Vietnam Era veterans. It covers several categories of veterans from World War II, the Korean conflict, the Vietnam era, and the Persian Gulf War which is defined as occurring from August 2, 1990 to the present.

If you believe you belong to any of the categories of protected veterans please indicate by checking the appropriate box below. The categories are defined on the next page and explained further in an “Am I a Protected Veteran?” infographic provided by OFCCP.

Please check one of the boxes below: I identify as one or more of the classifications of protected veteran I am not a protected verteran I Don’t Wish To Answer

Type Name to Agree

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