Employment Application

General Information

First Name Middle Name Last Name Maiden/Previous Name Social Security # Address Line 1 Address Line 2 City State ZIP Code Primary Phone Secondary Phone E-mail Address How did you hear about this job?

Are you under 18 years of age? Yes No

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

If Yes, please indicate which language(s) you speak

Job Specific Information

Position Applying For Date Available to Begin Work

Employment Preference Full-Time Part-Time Any

If applying for temporary or seasonal employment check here Rate of Pay Desired $

Pay Rate Hour Year

Days/Hours Available to Work

Day	Start Time	End Time
Monday	Start	End
Tuesday	Start	End
Wednesday	Start	End
Thursday	Start	End
Friday	Start	End
Saturday	Start	End

In which of our offices are you willing to work Any Brookfield Germantown Hartford Jackson Kewaskum Pewaukee Slinger Seven Hills West Bend Downtown West Bend West

Are you an experienced operator of any of the following (Select all that apply) Calculator Cash Drawer Coin Machine Microsoft Office Other

Please explain

Have you ever been convicted of a felony or misdemeanor, or do you have any charges pending against you Yes No

If yes, please explain

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.

Have you ever paid a civil forfeiture or fine for a non-traffic related offense Yes No

If yes, please explain

Payment of a civil forfeiture or fine will not be an automatic bar to employment and will be considered only as it relates to the job in question.

List below any personal characteristics, skills, attitudes, or achievements which you feel would qualify you for a position with westbury bank. Feel free to list any participation in community/civic activities, special achievements, awards, hobbies, etc.

Education History

High School

Name City, State

Last year completed 1 2 3 4

Did you graduate Yes No

College or Business/Trade School

Name City, State Major

Last year completed 1 2 3 4 5 6

Did you graduate Yes No

Degree

Graduate Studies

Name City, State Major

Last year completed 1 2 3 4 5 6

Did you graduate Yes No

Degree

Other

Name City, State Major

Last year completed 1 2 3 4

Did you graduate Yes No

Degree

Employment History

Check if no previous employer

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

Employer

Position Company Name Address City State Start Date End Date Most Recent Wage

May we contact this employer Yes No

First and Last Name of Supervisor Title of Supervisor Supervisor E-mail Supervisor Phone Number Reason for Leaving Duties

References

*Please provide 3 professional references who know of your work experience.

Professional Reference

Name Relationship Phone

Voluntary Self-Identification Information

In an effort to satisfy our voluntary government affirmative action program record keeping and reporting requirements, we ask that you complete this data survey. The information concerning status as an individual with a disability and veteran status may also be used to help you take advantage of the Company's affirmative action program for individuals with a disability and covered veterans. Your cooperation is appreciated. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not affect your application, subject you to discharge or discipline, or any other negative personnel action. Information provided will be kept confidential in accordance with applicable regulations.

Gender Male Female I choose not to disclose this information

Ethnicity Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race) Not Hispanic or Latino (if not Hispanic or Latino, please address race below) I choose not to disclose this information

Race (do not respond if you selected Hispanic or Latino above) White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North 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 American Indian 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 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 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 I choose not to disclose this information

Veteran Status

Descriptions

The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran

Disabled Veteran

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 a serviceconnected disability.

Recently Separated Veteran

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.

Active Duty Wartime or Campaign Badge Veteran

An "active duty wartime or campaign badge veteran" means a veteran who served 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.

Armed Forces Service Medal Veteran

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.

Veteran Status I am a Protected Veteran I am not a Protected Veteran I choose not to disclose the information

If yes, please give dates of service and name of war, campaign or expedition

Voluntary Self-Identification of Disability

Why are you being asked to complete the form?

How do I know if I have a disability?

I understand how to categorize a disability after reading the above information.

Disability Status (Please select one 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

If yes, please explain and suggest any ways we can accommodate your disability to assist you in performing your job. Use back side of this sheet for additional space, if necessary

Employee Application Authorization

Applicant Informed Consent and Release of Liability

Westbury bank has a vital interest in maintaining safe, healthful and efficient working conditions for its employees. Being under the influence of drug or controlled substance on the job may pose a serious safety and health risk not only to the user but to all those who work with the user. The possession, use or sale of an illegal drug or controlled substance in the workplace also poses unacceptable risks for safe, healthful and efficient operation.

I UNDERSTAND that according to westbury bank's policy, if I am offered a position, I would be required to pass a clinically accepted drug test, administered or directed by westbury bank's authorized medical professional. I understand that this test would be a condition of employment.

THE PURPOSE of this analysis would be to determine the presence of drugs or other chemicals. All information derived from this test would be kept confidential and released only to those Company personnel with a need to know.

I CONSENT freely and voluntarily to provide a specimen for drug/chemical analysis should I be offered a position. I also consent to the release of the result(s) of this analysis to the Company. I hereby release westbury bank and the laboratory, their employees, agents and contractors from any liability whatsoever, arising from a future request to furnish a specimen, the testing of a specimen, and decisions concerning my employment based upon the results of the analysis.

I understand and agree that future circumstances, accidents, incidents or workplace conditions may arise which cause the Company to request a specimen for chemical analysis at that time. My signature is an acknowledgement that I have read and understand this document and westbury bank's Drug Free Workplace Policy.

By checking this box, I acknowledge that I have read and understand the Applicant Informed Consent and Release of Liability

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

I also understand that my employment at westbury bank is contingent upon the satisfactory completion of a drug screen, finger-printing results, 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 westbury bank, which may include drug screening.

I understand that if I am employed by westbury bank, any such employment is not binding on either party for any specific period of time. I further understand that no representative of westbury 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 westbury 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 westbury bank or I may terminate that employment relationship at any time, for any reason, with or without notice.

By checking this box, I acknowledge that I have read and understand the employee application authorization