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Employment Application

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

First Name Middle Initial Last Name
Present Address  State  ZIP Code   
Home Phone  Work Phone 
Previous Address  State  Zip   
Social Security #  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 Shift Work
Will you work overtime if required? Yes  No
Are you legally eligible to work in the United States? Yes  No
Have you ever applied here before? Yes  No
If Yes, which location?
Have you been employed here previously? Yes  No

If Yes, give dates 
If Yes, which Location?
Do you have a relative who works here? Yes  No
Have you ever been convicted of a felony?
Note: A "yes" answer to this question will not necessarily result in your application being denied.
Yes No
Were (are) you in the U.S. Armed Forces? Yes No
If Yes, w hich branch?

EMPLOYMENT HISTORY

Company Name Phone
Address 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
Company Name Phone
Address 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
Company Name Phone
Address 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
Company Name Telephone Number
Address 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
If presently employed, why do you desire to change positions?
If presently employed, may we contact your current employer? Yes  No
Have you ever been asked to resign or been terminated from a position of employment? Yes  No

EDUCATION

High School Name Address
Course of Study Dates Attended
Did you Graduate?  Yes  No Diploma or Degree
College Name Address
Course of Study Dates Attended
Did you Graduate?  Yes  No Diploma or Degree
Other Educational Institution Address
Course of Study Dates Attended
Did you Graduate?  Yes  No Diploma or Degree
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
If yes, 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  speak read write
Language  speak read write

 

Please check the following skills in which you are proficient: 

Typing 10 Key adding machine Personal Computer
(wpm)  by sight  Proof Machine
Shorthand by touch  Word Processing
(wpm)    Teller Machine   Loan Note Computer
Calculator   PBX   Other:
Dictaphone   CRT    
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 Basile State Bank, (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 Basile State Bank, 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 Basile State Bank, 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 Basile State Bank, 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.

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

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