Employment Application

Required Field


Have you lived here for two or more years?

How would you prefer to be contacted?

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

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?

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.

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?


What was your last year completed?

Did you graduate?

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.


May we contact this employer?

Add Another Employer


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

Reference 1

Reference 2

Reference 3

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.

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.

Please select from the following Equal Employment Opportunity Identification Group:

Veteran Status: Please mark all that apply.