PERSONAL

Social Security Number

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Referred By

Are you 18 years of age or older?

Yes

EMPLOYMENT DESIRED

Position

Date You Can Start

YYYY

Salary Desired

Are you employed now?

Yes

If so, may we inquire of your present employer?

Yes

Ever applied to this credit union before?

Yes

If so, Where?

If so, When?

YYYY

EDUCATION

Grammar School

Name and Location

Graduated?

Yes

Subjects Studied and Degree(s) Received

High School

Name and Location

Last Year Completed

Graduated?

Yes

Subjects Studied and Degree(s) Received

College

Name and Location

Last Year Completed

Graduated?

Yes

Subjects Studied and Degree(s) Received

Trade, Business or Correspondence School

Name and Location

Last Year Completed

Graduated?

Yes

Subjects Studied and Degree(s) Received

GENERAL

Subjects of Special Study or Research Work

Job Related Skills (typing, driver's license, etc.)

FORMER EMPLOYERS

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

Employer 1

Start Date

YYYY

End Date

YYYY

Salary (upon leaving)

Reason for Leaving

Name of Employer

Address of Employer

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position

Employer 2

Start Date

YYYY

End Date

YYYY

Salary (upon leaving)

Reason for Leaving

Name of Employer

Address of Employer

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position

Employer 3

Start Date

YYYY

End Date

YYYY

Salary (upon leaving)

Reason for Leaving

Name of Employer

Address of Employer

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position

Employer 4

Start Date

YYYY

End Date

YYYY

Salary (upon leaving)

Reason for Leaving

Name of Employer

Address of Employer

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position

REFERENCES

Reference 1

Name

First Name

Last Name

Position

Years Acquainted

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Reference 2

Name

First Name

Last Name

Position

Years Acquainted

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Please read the following disclosure and scroll down to submit this application.

If you are hired, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

AUTHORIZATION: I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the employer.

I understand that any employment is conditioned on a background check. I authorize the financial institution to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the credit union, without giving me prior notice of such disclosure. In addition, I release the financial institution, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during my interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the financial institution. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the financial institution unless made in writing.

If I am offered employment I agree to submit to a medical examination and drug test, if required, before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the credit union and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the financial institution the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, may be contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by the financial institution's Drug and Alcohol Policy.

I understand that filling out this form does not indicate there is a position open and does not obligate the financial institution to hire. If hired, I agree to abide by all financial institution work rules, policies and procedures. The financial institution retains the right to revise its policies or procedures, in whole or in part, at any time.

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