Application for Employment

This institution does not unlawfully discriminate in any employment practice on the basis of race, color, age, religion, national origin, sex, veteran status or disability. No question on this application is intended to secure information which could be of a discriminatory nature.

APPLICANT INFORMATION

Name*

First Middle Last

Present Address*

Street Address City State ZIP Code

Home Phone*

Phone

Email*

Previous Address*

Street Address City State ZIP Code

May we contact you at your present employer?*

Yes
No

Driver's License #*

State of Issue*

Position Applying for*

Salary Desired*

Referred by*

Date Available for Work*

Are You Available to Work: (Check all that apply.)*

Full Time
Part Time
Temporary
Shiftwork

Will you work overtime if required?*

Yes
No

Are you legally eligible to work in the United States?*

Yes
No

Have you been bonded?*

Yes
No

Have you ever applied here before?*

Yes
No

Which location?*

Have you been employed here previously?*

Yes
No

Give Dates*

Which Location did you work at before?*

Do you have a relative who works here?*

Yes
No

EMPLOYMENT HISTORY

Company Name*

Phone*

Employer Address*

Street Address City State ZIP Code

Employed from (Mo/Yr) to (Mo/Yr)*

Name of Supervisor/Title*

Starting Hourly Rate/Salary*

Final*

How would this supervisor rate your job experience?*

Above Average
Average
Below Average

Your title/job duties*

Reason for leaving*

Second Previous Company Name*

Second Previous Company Phone*

Second Previous Employer Address*

Street Address City State ZIP Code

Employed from (Mo/Yr) to (Mo/Yr) at Second Previous Company*

Name of Supervisor/Title at Second Previous Company*

Starting Hourly Rate/Salary at Second Previous Company*

Final Salary at Second Previous Company*

How would this supervisor rate your job experience at Second Previous Company?*

Above Average
Average
Below Average

Your title/job duties at Second Previous Company*

Reason for leaving your Second Previous Company?*

Third Previous Company Name*

Third Previous Company Phone*

Third Previous Employer Address*

Street Address City State ZIP Code

Employed from (Mo/Yr) to (Mo/Yr) at Second Previous Company*

Name of Supervisor/Title at Third Previous Company*

Starting Hourly Rate/Salary at Third Previous Company*

Final Salary at Third Previous Company*

How would this supervisor rate your job experience at Third Previous Company?*

Above Average
Average
Below Average

Your title/job duties at your Third Previous Company*

Reason for leaving your Third Previous Company*

EDUCATION

High School Name*

High School Address*

Street Address City State ZIP Code

Course of Study*

Did you Graduate?*

Yes
No

Diploma or Degree*

College Name*

College Address*

Street Address City State ZIP Code

College Course of Study*

Did you Graduate College?*

Yes
No

Diploma or Degree from College?*

Other Educational Institution Address

Street Address Address Line 2 City State ZIP Code

Other Educational Institution

Course of Study at Other Educational Institution

Did you Graduate from Other Educational Institution?*

Yes
No

Diploma or Degree at Other Educational Institution

List any scholastic honors, offices held, and activities in High School:*

List any scholastic honors, offices held, and activities in College:*

Do you have any plans for further education?*

Yes
No

Explain*

Optional: Are there any special skills you would like to include that you feel might better qualify you for the job. (You may wish to include civic and community activities, professional societies or special training such as typing, accounting, etc.) Do not include information which would reveal sex, race, color, age, national origin, religion, veteran status or disability.

Please select the level of fluency with foreign languages, if any?

Language 1

Language 1 Proficiency

Speak
Read
Write

Language 2

Language 2 Proficiency

Speak
Read
Write

Please check the following skills in which you are proficient:*

Typing (WPM)*

Shorthand WPM*

10 Key Adding Machine By Sight*

10 Key Adding Machine by Touch*

Other: Explain*

PLEASE READ CAREFULLY BEFORE SUBMITTING THE APPLICATION. (If you have any questions regarding this statement, please ask a representative of the Human Resources Office before signing.) I certify that answers given herein are true and complete. I authorize Exchange Bank, ssb (hereafter referred to as "the Bank") to investigate all statements in this application and to secure any necessary information from all my employers, references and academic institutions. I also authorize the Bank to secure financial and credit information through an appropriate agency. I understand that I have the right to request that Exchange Bank, ssb completely and accurately disclose to me the source(s) of the credit information obtained. Such a request must be made in writing to the Human Resources Office of the Bank within a reasonable time after completion of this application. Additionally, I authorize the Bank to supply my employment record, in whole or in part, and in confidence, to any prospective employer, government agency, or other party, with a legal and proper interest. I further understand that any false information, misleading statements or omission of facts will be sufficient cause for rejection of my application if the Bank has not employed me and for immediate dismissal if the Bank has employed me. I also understand that the Bank has the right to modify any of its policies without giving prior notice of the changes to me. This application will be given every consideration, but its receipt or communication with any Exchange Bank, ssb official does not imply that the applicant will be employed. I understand that if an employment relationship is established, I have the right to terminate my employment at any time for any reason. I also understand that the Bank retains the right to terminate my employment at any time for any reason. No supervisor or officer of the Bank has the authority to modify, in any way, the "at will" employment relationship unless such modification is reduced to a formal written agreement and signed by the President of the Bank. In the event of my employment with the Bank, I will comply with all rules, regulations, and policies set forth in the Bank's policy manuals or other communications distributed by the Bank. In addition, I do hereby pledge myself to observe in confidence and not disclose any information relating to Exchange Bank, ssb business with any person, firm or corporation, except such matters that I may have express authority from an authorized officer of the Bank to disclose. I understand the Bank promotes an alcohol/drug free workplace. I agree to abide by the guidelines set forth in the Bank's alcohol/drug abuse policy.

Consent*

I hereby acknowledge that I have read and understand the preceding statements.

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