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Employment History

Company Name:

Complete Address:

Phone:

Supervisor:

Job Title:

Responsibilities:

Monthly Starting Salary:

Monthly Ending Salary:

Start Date (mm/dd/yyyy):

End Date (mm/dd/yyyy):

Reason for Leaving:

May we contact your previous employer for a reference?
Yes No

Describe the skills and aptitudes you possess that would qualify you for a position with FLB:

Education

High School:

HS Address:

HS Graduate:
Yes No

HS Degree:

Trade/Business School:

Trade/Business Address:

Trade/Business Graduate:
Yes No

Trade/Business Degree:

College:

College Address:

College Graduate:
Yes No

College Degree:

Graduate Work/Other:

Address:

Graduate:
Yes No

Degree:

1st Language Known:

1st Language - Answer All That Apply:
Speak Read Write

1st Language - Fluency:
Good Fair

2nd Language Known:

2nd Language - Answer All That Apply:
Speak Read Write

2nd Language - Fluency:
Good Fair

3rd Language Known:

3rd Language - Answer All That Apply:
Speak Read Write

3rd Language - Fluency:
Good Fair

Personal References

Please list three references not related to you and who are not previous employers

Reference #1 Name:

Reference #1 Occupation:

Reference #1 Years Known:

Reference #1 Phone Number:

Reference #1 Address:

Reference #2 Name:

Reference #2 Occupation:

Reference #2 Years Known:

Reference #2 Phone Number:

Reference #2 Address:

Reference #3 Name:

Reference #3 Occupation:

Reference #3 Years Known:

Reference #3 Phone Number:

Reference #3 Address:

Professional References

Please list three professional references.

Prof. Reference #1 Name:

Prof. Reference #1 Occupation:

Prof. Reference #1 Years Known:

Prof. Reference #1 Phone:

Prof. Reference #1 Address:

Prof. Reference #2 Name:

Prof. Reference #2 Occupation:

Prof. Reference #2 Years Known:

Prof. Reference #2 Phone:

Prof. Reference #2 Address:

Prof. Reference #3 Name:

Prof. Reference #3 Occupation:

Prof. Reference #3 Years Known:

Prof. Reference #3 Phone:

Prof. Reference #3 Address:

Please list professional, trade, business, or civic associations and any offices held. (Exclude organizations which would reveal sex, race, religion, national origin, age, disability, veteran or other protected status.)

Organization #1:

Offices Held #1:

Organization #2:

Offices Held #2:

Organization #3:

Offices Held #3:

Organization #4:

Offices Held #4:

List special accomplishments, publications, awards. (Exclude information which would reveal sex, race, religion, national origin, age, disability, veteran or other protected status.)

Employment Data Record

First Liberty Bank is an affirmative action employer, and does not discriminate, and is subject to Federal regulations requiring reporting of certain information on applicants for employment. To assist in this effort, all applicants are requested to complete this form. Your cooperation is strictly voluntary. This form will be kept separate from your employment application and the information contained will be kept confidential. It will not be available to personnel involved in the hiring process. The information given will be used only for reporting purposes in accordance with Federal laws and regulations.

If you do not wish to provide this information, please print your name, the date and please indicate such fact in the appropriate space below. Your decision in this regard will not affect your application.

Gender:
Male Female

Check here if you do not wish to provide the information requested below

Today's Date:

Position Applied For:

Applicant First Name:

Applicant Last Name:

Applicant Address:

Applicant Apartment/Unit #:

Applicant City:

Applicant State:

Applicant Zip:

Applicant Social Security Number:

Race/Ethnic Categories (Check one):
White
Hispanic or Latino
Black or African American (not Hispanic or Latino)

Asian (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

American Indian/Alaskan Native (not Hispanic or Latino)
Two or More Races

Disability Status (Check one):
Yes, I have a disability
No, I don't have a disability

Applicant's Statement

Notification and Agreement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize the Bank to investigate all statements in this application and to secure any necessary information from all my employers, references and academic institutions. I authorize the Bank to investigate criminal court records and as a result I will be requested to complete an Authorization to Obtain Consumer and Investigative Consumer Report form.

I understand that any offer of employment is contingent upon receipt of a satisfactory report concerning my credit, academic credentials, and employment references. Because of amendments to the Fair Credit Reporting Act in 1997, I understand that extra procedures are required of the Bank. Thus, I will be notified as to those procedures if my application for employment necessitates a credit report. 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.

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 manual or other communications distributed by the Bank. 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.

Further, I understand that I must immediately notify the Bank if I am convicted of, receive deferred adjudication in, or otherwise plead guilty or no contest to a felony, or any criminal offense involving dishonesty or a breach of trust or money laundering, while my application is pending or during my tenure as an employee of the Bank.

I understand that nothing in this employment application, in the Bank's policy statements or personnel guidelines, or in my communications with any Bank official is intended to create an employment contract between the Bank and me. I also understand that the Bank has the right to modify any of its policies without giving notice of the changes to me. No promises of employment have been made to me. I acknowledge that the Bank employs individuals under the employment-at-will doctrine and that this is not subject to any changes. 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.

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

Signature:

Date:

Application for Employment

Applicant Information

Employment History

Education

Personal References

Professional References

Employment Data Record

Applicant's Statement

Notification and Agreement

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