Employment Application

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability or national origin. Consistent with the Americans Disabilities Act, applicants may request accommodations needed to participate in the application process.

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The items marked with (*) are required fields.


Personal Information
Social Security Number --
*Last Name
*First Name
Middle Name
 
Address 1
Address 2
City
State
ZIP code -
 
Email Address
 
Phone Number --
 
Are you 18 years of age or older? Yes No
 
Driver's License Number
State that issued driver's license
 
Are you a citizen of the United States Yes No
If NO, do you have authorization to work in the United States? Yes No
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Employment Desired
Position
Date You Can Start //
Rate of pay expected $ per hour week year
Do you need full-time employment? Yes No
Will you consider part-time? Yes No
Number of hours desired per week
Days of the week available to work:  
Mon Tue Wed Thur Fri Sat
   
Are you employed now? Yes No
If so, may we inquire of your present employer? Yes No
What other employment of "Side Line" business do you have?
Would you want to continue this if employed by us? Yes No
   
Have you even been convicted of a crime?
(A conviction will not automatically bar you from employment.)
Yes No   If YES, list dates and details.
   
How were you referred to us?
Employee Friend School Agency Ad Other
   
Ever applied to this credit union before? Yes No
If so, Where?
If so, When? //
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Education
High School
Name and Location
Graduated? Yes No
Subjects Studied and Degree(s) Received
College
Name and Location
From: // To://
Graduated? Yes No
Subjects Studied and Degree(s) Received
Trade, Business or Correspondence School
Name and Location
From: // To://
Graduated? Yes No
Subjects Studied and Degree(s) Received
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General
Subjects of Special Study or Research Work
Job Related Skills (typing, driver's license, etc.)
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Employment History

List below the last three employers, starting with the most recent one first.

Start Date //
End Date //
Position
Salary (upon leaving)
Reason for Leaving
Name of Employer
Address 1 of Employer
Address 2 of Employer
City of Employer
State of Employer
Zip of Employer -
Phone Number of Employer
May we contact this employer? Yes No
Immediate Supervisor
Supervisor Title
 
Start Date //
End Date //
Position
Salary (upon leaving)
Reason for Leaving
Name of Employer
Address 1 of Employer
Address 2 of Employer
City of Employer
State of Employer
Zip of Employer -
Phone Number of Employer
May we contact this employer? Yes No
Immediate Supervisor
Supervisor Title
 
Start Date //
End Date //
Position
Salary (upon leaving)
Reason for Leaving
Name of Employer
Address 1 of Employer
Address 2 of Employer
City of Employer
State of Employer
Zip of Employer -
Phone Number of Employer
May we contact this employer? Yes No
Immediate Supervisor
Supervisor Title
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Any periods of unemployment? Yes No
If YES, please explain
List your skills, abilities, hobbies, training, etc. that you feel may be an asset
Have you ever been covered by a surety bond? Yes No
Have you even been denied surety bond or had such coverage revoked? Yes No
Have you had any experience in the Armed Forces of the United States, National Guard or Reserves? Yes No
If YES, what branch?
Rank at discharge
Date of discharge
Special technical training
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References
Last Name
First Name
Years Acquainted
Address 1
Address 2
City
State
Zip -
Phone Number --
 
Last Name
First Name
Years Acquainted
Address 1
Address 2
City
State
Zip -
Phone Number --
 
Last Name
First Name
Years Acquainted
Address 1
Address 2
City
State
Zip -
Phone Number --
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PLEASE READ THE FOLLOWING:

I authorize an investigation and verification of my employment, education, criminal conviction and financial record. I authorize my employer and former employers, references, credit reporting agencies/bureaus, medical facilities, educational institutions, and any other persons contacted by the credit union to provide it with all records and information relevant to this employment application without any obligation to give me written notice thereof, and I release all such parties from all liabilities arising from such disclosures. I also waive any claims against the credit union relating to such inquiries and disclosures and release the credit union, its directors, officers, employees and agents from any liability which might arise from such inquiries and disclosures.

I understand that I may be required to undertake a post offer physical examination, including a drug and alcohol test, in connection with my application for employment. Such examination would be conducted by a physical or clinic selected by the credit union. I hereby authorize any such physician or clinic to release to the credit union such information derived from that examination as the credit union requires. I waive any claims that I might have on account of the physical examination (including the drug and alcohol test) requirement and the release of the physical examination (including the drug and alcohol test) information to the credit union.

I understand that the credit union will accommodate, to the extent required by law, employees with disabilities to allow access to its facilities and employment opportunities. I also understand that I have 182 days from this date, or the date I know that such accommodation is needed, to file a written request for such accommodation.

I agree that this application will be considered for the period of six (6) months after this date. I understand and acknowledge that unless I am hired before the end of this six-month period, this application will be null and void and any continuing interest in the credit union will require a new application.

I agree not to begin any action or suit, not expressly waived in this application, related to my employment with the Credit union more than six months after the date of the termination of such employment and to waive any statute of limitations to the contrary.

If employed, I agree to abide by all rules and regulation of the credit union.

To the best of my knowledge, the above statements are true and I understand, if employed, any false information or material omissions may be cause for discipline or discharge.



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