Employment Application

Required Field

Applicant

First Name Middle Initial Last Name Suffix Mother's Maiden Name Mailing Address City State Zip Code Physical Address City State Zip Code

Have you lived here for two or more years?

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 needed if under 18

Are you legally eligible for employment in this country?

Job Specific Information

Position Applying For

What is your employment preference?

Any
Full-Time
Part-Time
Temporary Employment

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

Are you willing to work overtime if requested to do so?

Will you travel if the job requires it?

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.

If yes, please explain

Education History

High School

Name of School Address of School City State Zip Code

What was your last year completed?

Did you graduate?

College/Trade School

Name Address City State Zip Code Major

What was your last year completed?

Did you graduate?

Degree/Diploma

Graduate Studies

Name Address City State Zip Code Major

What was your last year completed?

Did you graduate?

Degree/Diploma

Other

Name Address City State Zip Code Major

What was your last year completed?

Did you graduate?

Degree/Diploma

Employment History

Have you been employed before?

Starting with the present or most recent, list all previous employers. Include self-employment, military service, summer and part-time jobs. Please only go back 10 years, unless you have held positions that are directly applicable to the position that you are applying for that exceed the 10 year limit.

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?

 Add Another Employer

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

Employee Application Authorization

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 Independence 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 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 Independence 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 Independence Bank may deny me employment or terminate my employment, and I agree that Independence Bank shall not be liable in any respect if it does so.

I understand that if I am employed by Independence Bank, any such employment is not binding on either party for any specific period of time. I further understand that no representative of Independence Bank, other than the Vice President of Human Resources, 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 Independence 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 Independence 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

Voluntary Affirmative Action and Veteran Status Data

Please note: Completion of this section is voluntary. We consider all applicants for positions without regard to race, color, religion, sex, national origin, sexual orientation, citizenship, age, mental or physical disabilities, veteran, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

Providing the following information is STRICTLY VOLUNTARY. Not providing it will not subject you to any negative personnel decision or action. Your cooperation is appreciated.

Male
Female

Please select from the following Equal Employment Opportunity Identification Group:

Hispanic or Latino
White
Asian
Native Hawaiian/Other Pacific Islander
Black/African American
American Indian/Alaskan Native
Two or More Races

Veteran Status: Please mark all that apply.

A "disabled veteran" is one of the following: A 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

A person who was discharged or released from active duty because of service-connected disability A "recently separated veteran" means 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 "active-duty wartime or campaign-badge veteran" means a veteran who, while serving 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. An "Armed forces service medal veteran" means a veteran who, while serving 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. I am not a protected veteran

Applicant

Have you lived here for two or more years?

How would you prefer to be contacted?

Are you under 18 years of age?

Are you legally eligible for employment in this country?

Job Specific Information

Which location(s) are you applying for?

What is your employment preference?

Are you willing to work overtime if requested to do so?

Will you travel if the job requires it?

Have you ever been convicted of a felony or misdemeanor, or do you have any charges pending against you?

Education History

High School

What was your last year completed?

Did you graduate?

College/Trade School

What was your last year completed?

Did you graduate?

Graduate Studies

What was your last year completed?

Did you graduate?

Other

What was your last year completed?

Did you graduate?

Employment History

Have you been employed before?

Employer

May we contact this employer?

References

Reference 1

Reference 2

Reference 3

Employee Application Authorization

Voluntary Affirmative Action and Veteran Status Data

Please select from the following Equal Employment Opportunity Identification Group:

Veteran Status: Please mark all that apply.