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Employment Application

General Information

Are you under 18 years of age?
Are you fluent in any language(s) other than English

Job Specific Information

Employment Preference
Pay Rate

Days/Hours Available to Work

Day Start Time End Time
In which of our offices are you willing to work
Are you an experienced operator of any of the following (Select all that apply)
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.

Have you ever paid a civil forfeiture or fine for a non-traffic related offense

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.

Education History

High School

Last year completed
Did you graduate

College or Business/Trade School

Last year completed
Did you graduate

Graduate Studies

Last year completed
Did you graduate


Last year completed
Did you graduate

Employment History

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


May we contact this employer


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

Professional Reference

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.

Race (do not respond if you selected Hispanic or Latino above)

Veteran Status


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

Voluntary Self-Identification of Disability

Why are you being asked to complete the form?

How do I know if I have a disability?

Disability Status (Please select one below)

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.

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.

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