220 S Detroit St. LaGrange, IN (260)

Transcription

1 220 S Detroit St. LaGrange, IN (260) Farmers State Bank ( the Company ) is an Equal Opportunity Employer. It is the policy of the Company to afford equal employment opportunity regardless of race, religion, color, national origin, sex, age, marital status, height, weight, familial status, veteran status, or disability. State law may require that a person with a disability requiring accommodation for employment must notify the employer in writing within 182 days after the need is known. A person with a disability or handicap requiring accommodation for completing the application process should notify the Human Resources Department as soon as possible. PERSONAL INFORMATION APPLICATION FOR EMPLOYMENT Date Last First Middle Maiden Present address Number Street City State Zip Telephone ( ) EMPLOYMENT DESIRED Position(s) applied for desired FULL-TIME ONLY PART-TIME ONLY PRIME- TIME ONLY When are you available to start work? Page 1 of 5

2 EDUCATION TYPE OF SCHOOL High School NAME OF SCHOOL & LOCATION QUALIFICATION OBTAINED MAJOR & SPECIALIZATION NUMBER OF YEARS COMPLETED College/ University Professional or Graduate School WORK EXPERIENCE Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary. Your Last Job Title Page 2 of 5

3 Are you currently employed? Yes No May we contact your present employer? Yes No Did you complete this application yourself? Yes No If not, who did? Page 3 of 5

4 Have you ever been convicted of a felony? Yes No If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. Have you ever been employed with this company? Yes No If yes, when? Do you have any friends or relatives employed by this company? Yes No If yes, please provide their names and relationship to you. REFERENCES Please list below three persons not related to you who have knowledge of your work performance and/or personal qualifications within the last 5 years. Page 4 of 5

5 PLEASE READ CAREFULLY AND SIGN BELOW I affirm that the information provided on this application (and accompanying resumé, if any) is true and complete. I also agree that any false information, misrepresentations, or omissions may disqualify me from further consideration for employment and may result in discipline or dismissal if discovered at a later date. I authorize the Company to investigate all statements contained in this application, including disciplinary records of any former employers, police departments, and other references or sources concerning me. I authorize all such references and sources to release this information without liability for damage incurred in giving it. I waive any written notice of the release of such records that may be required by state or federal law. I also understand that if I have a protected disability that affects my ability to do the job I seek, I may ask the Company to attempt to make a reasonable accommodation for it. I must make my request in writing to the Human Resources Department as soon as possible, and under the Michigan Persons With Disabilities Civil Rights Act if employed in Michigan, such notice must be given no later than 182 days after the date I know or reasonably should know that accommodation is needed. I understand that employees of the Company are employed on an indefinite basis and are subject to termination at any time, with or without notice, discipline, or warning, for any or no reason. No person other than the President of the Company has authority to offer employment for any specified period or to make any contract contrary to the foregoing. Moreover, no such agreement by the President will be enforceable unless it is in writing, pertains specifically to me, and is signed by the President. Dated: Applicant signature Page 5 of 5