INSTRUCTIONS: Please complete all portions of this employment application to be considered for employment. If you require accommodation during the employment process, including assistance in the completion of this employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a three month period after submission to the credit union and only for the desired position. Consideration for employment after the three-month period requires completion and submission of a new application.

* indicates a required field.

*Social Security Number:

Social Security Number SSN Part 1 - Social Security Number SSN Part 2 - Social Security Number SSN Part 3

(for bondability and criminal conviction checks)

Present Address:

Present Address Street

Present Address Apartment Number

Present Address City

Present Address State

Present Address Zip Code

Mailing Address(if different than above):

Mailing Address(if different than above) Street

Mailing Address(if different than above) Apartment Number

Mailing Address(if different than above) City

Mailing Address(if different than above) State

Mailing Address(if different than above) Zip Code

Work:

Work Area Code( ) Work Part 1 - Work Part 2 Work Extensionext:

Alternate Phone:

Alternate Phone Area Code( ) Alternate Phone Part 1 - Alternate Phone Part 2 Alternate Phone Extensionext:

*Have you ever used any other names?

Yes  No

(for background and criminal conviction checks)

If yes, please explain:

*Have you ever been convicted of a crime or entered a pretrial diversion program to avoid a conviction?

Yes  No

If yes, please list:

*Position applying for:

*Pay expected:

*Have you applied for work with us before?

Yes  No

Where?

When?

Where?

When?

*Apart from religious services, will you be able to work all other times?

Yes  No

(If hired, you will be required to perform work as required by the credit union.)

*Who referred you to us?

Relative

Employment Agency

Newspaper Ad

Friend

State Employment Office

College Placement Service

Walk in

Other

*High School:

Major:

Years There:

Technical School:

Major:

Years Spent:

Graduated?

Yes  No

Degree/Diploma:

College:

Major:

Years Spent:

Graduated?

Yes  No

Degree/Diploma:

College:

Major:

Years Spent:

Graduated?

Yes  No

Degree/Diploma:

Graduate School:

Major:

Years Spent:

Graduated?

Yes  No

Degree/Diploma:

Other:

Major:

Years Spent:

Graduated?

Yes  No

Degree/Diploma:

Starting with your present or last job, provide complete employment history for the last 10 years. You must answer all questions and this employment history must be completed even if you submit a resume.

1. Name of Employer:

Phone Number:

Phone Number Area Code( ) Phone Number Part 1 - Phone Number Part 2 Phone Number Extensionext:

Employer Address:

Employer Address Street

Employer Address City

Employer Address State

Employer Address Zip Code

Ending Date of Employment:

Position Title and Duties:

Reason for leaving

May we contact this employer?

Yes  No

If no, explain:

2. Name of Employer:

Phone Number:

Phone Number Area Code( ) Phone Number Part 1 - Phone Number Part 2 Phone Number Extensionext:

Employer Address:

Employer Address Street

Employer Address City

Employer Address State

Employer Address Zip Code

Ending Date of Employment:

Position Title and Duties:

Reason for leaving

May we contact this employer?

Yes  No

If no, explain:

3. Name of Employer:

Phone Number:

Phone Number Area Code( ) Phone Number Part 1 - Phone Number Part 2 Phone Number Extensionext:

Employer Address:

Employer Address Street

Employer Address City

Employer Address State

Employer Address Zip Code

Ending Date of Employment:

Position Title and Duties:

Reason for leaving

May we contact this employer?

Yes  No

If no, explain:

Please provide the names of three persons you are not related to, you have known at least one year and whom we may contact.

*Phone:

Phone Area Code( ) Phone Part 1 - Phone Part 2 Phone Extensionext:

*Yrs. known:

*Phone:

Phone Area Code( ) Phone Part 1 - Phone Part 2 Phone Extensionext:

*Yrs. known:

*Phone:

Phone Area Code( ) Phone Part 1 - Phone Part 2 Phone Extensionext:

*Yrs. known:

*Summarize your job skills, training and/or study that are relevant for the desired position. Also, explain any periods that you were not working.

CERTIFICATION

 

PLEASE READ CAREFULLY BEFORE SIGNING

1. I certify that the information in this application is true, correct, and complete. I understand that any false or misleading statements or omissions made in this application or interview(s) are grounds for disqualification from further consideration or for dismissal from employment, regardless of when and how discovered.
2. I understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY REASON WITH OR WITHOUT ADVANCE NOTICE
3. I understand and agree that only the President/CEO of Credit Union Name (here-in-after referred to as “CU Name Abbreviation”) has any authority to enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my employment. I agree that such an agreement must be in writing and signed by the President/CEO, and I will not rely upon any other representations regardless of the source
4. I understand and agree that “CU Name Abbreviation” may make a full and complete investigation of my personal, financial or employment history, and authorize any former employer, person, firm, corporation, school, government agency, or other entity to provide “CU Name Abbreviation” with any information (including fact or opinion) they may have regarding me. In consideration of “CU Name Abbreviation” review of this application, I release “CU Name Abbreviation” and all providers of any information from any liability which may arise as a result of furnishing and receiving this information. I understand and agree any employment offer or continued employment shall be conditioned on the receipt of satisfactory references as determined by “CU Name Abbreviation”. If employed by “CU Name Abbreviation”, I further authorize “CU Name Abbreviation” to provide truthful information (including fact or opinion) regarding my employment to any potential or future employer and release and waive any claims against “CU Name Abbreviation” for truthfully communicating any such information to a potential or future employer.
5. I understand and authorize “CU Name Abbreviation” to obtain a consumer credit report as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for “CU Name Abbreviation” to obtain consumer credit reports at any time during my employment period.
6. I understand, agree and voluntarily consent to be tested for evidence of the presence of alcohol and/or drugs in my body through the analysis of my urine, breath (if permitted by law) or blood in the manner specified in the Employee Substance Abuse Policy. I further consent to the release of the results of the substance abuse tests by the medical laboratory facility to the Medical Review Officer designated by Credit Union Name (the “Credit Union”). I further consent to the release of verified positive test results for substance abuse by the Medical Review Officer for the Credit Union. I also understand that only those job applicants who have been selected to fill job openings will be subject to substance abuse testing. If a substance abuse test is required, a negative substance abuse test result will be a condition of actual hire. I further understand, agree and voluntarily consent to submit to random substance abuse testing that may be required during the term of my employment.
7. I understand and agree that “CU Name Abbreviation” may inquire into and consider any criminal conviction record that I may have, which bears a rational relationship to the duties and responsibilities of the position for which I am applying, in accordance with state and federal laws. In that regard, I understand that “CU Name Abbreviation” cannot hire or retain in employment a person who has been convicted of any criminal offense involving dishonesty or breach of trust, or has agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense, without the prior written consent of the National Credit Union Board (NCUA). I also understand and agree that being eligible for full bond and loss insurance coverage (without increased premiums or deductibles or other modifications or exceptions) is a condition for consideration for employment and if hired, a condition of continued employment.
8. I understand and agree that if offered employment by “CU Name Abbreviation”, I may be required to disclose military service information in accordance with law, and that any such employment offer shall be dependent upon the receipt of a satisfactory military record as determined by “CU Name Abbreviation”.
9. If hired, I agree not to disclose or use confidential information belonging to prior employers and that I will inform “CU Name Abbreviation” of any agreements that would limit my ability to work for “CU Name Abbreviation”.
10. I understand and agree that all of the foregoing terms and conditions will become part of my employment relationship with “CU Name Abbreviation”, if I am employed by “CU Name Abbreviation”.