Employment Application

Personal Data

First Name

MI

Last Name

Address Line 1

Address Line 2

City

State

ZIP

Phone Number

Phone Home Work Cell

Alternate Phone Number

Alternate Phone Home Work Cell

Email Address

Are you a citizen of the U.S. or can you submit verification of your legal right to work in the U.S.? Yes No

NOTE: New employees will be required to substantiate work eligibility status in compliance with the Immigration Reform and Control Act of 1986.

General Information

Position Apply For

Salary Requirement

Date Available

Work Status Desired Full-time Part-time Temporary Summer

If seeking part-time, hours available

Could you travel if required? Yes No

Have you ever submitted an application for employment here before? Yes No

If yes, when?

Have you ever been employed here or with any of our affiliates? Yes No

If yes, when and where?

Are you related to anyone currently employed by our organization? Yes No

If yes, please list name(s) and relationship(s)

Referral Source (please check all that apply)

Website

Staffing Agency

Job Posting/Newspaper Ad

Walk-in

Government Agency (IA Workforce Development)

Other

Name of Referrer (if applicable)

Have you ever been convicted of, or plead guilty or no contest to any misdemeanor or felony? Yes No

(Any criminal offense will not necessarily disqualify you from employment, but each offense will be evaluated based upon its nature, when it occurred and the type of position sought with the company.)

If yes, provide date(s) and details

This company practices equal employment opportunity. We do not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, gender bias, gender identity, disability, or status as a disabled or Vietnam era veteran. This form is designed to secure information that is job related; no question in this application form is intended to secure information that will be used for any unlawful or discriminatory purpose.

Education

High School

Name of School

City & State

Number of Years Completed

Did You Graduate? Yes No

Degree Earned Diploma GED

College

Name of School

City & State

Number of Years Completed

Did You Graduate? Yes No

Degree Earned Associate Bachelor's Other

If other, please list degree

Major

Graduate School

Name of School

City & State

Number of Years Completed

Did You Graduate? Yes No

Degree Earned Master's Other

If other, please list degree

Major

Other Education

Name of School

City & State

Number of Years Completed

Did You Graduate? Yes No

Degree Earned

Major

Work History

Please list your work experience beginning with your most recent job held. Please include at least the past five years, attach additional sheets if necessary.

Employer 1

Employer Name

Employer Address Line 1

Employer Address Line 2

City

State

ZIP

Employer Phone Number

Supervisor Name

May we contact this employer? Yes No

Employment Start Date

Employment End Date

Starting Salary

Final Salary

Status Full Time Part Time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Employer 2

Employer Name

Employer Address Line 1

Employer Address Line 2

City

State

ZIP

Employer Phone Number

Supervisor Name

May we contact this employer? Yes No

Employment Start Date

Employment End Date

Starting Salary

Final Salary

Status Full Time Part Time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Employer 3

Employer Name

Employer Address Line 1

Employer Address Line 2

City

State

ZIP

Employer Phone Number

Supervisor Name

May we contact this employer? Yes No

Employment Start Date

Employment End Date

Starting Salary

Final Salary

Status Full Time Part Time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Skills

Do you speak, read or write any languages other than English? Yes No

Second Language

Proficiency Speak Read Write

Third Language

Proficiency Speak Read Write

Computer Software Experience

1=Novice/Beginner, 5=Advanced/Expert)

Name of Publishing Software

Name of Program(s)

Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. Include courses taken in school, present or past positions, skills or special training, educational honors, or other experience you would like to have considered.

Additional Skills

Professional References

Please provide at least two business or professional references.

Reference 1

First Name

Last Name

Title

Address Line 1

Address Line 2

City

State

ZIP

Email Address

Phone Number

Reference 2

First Name

Last Name

Title

Address Line 1

Address Line 2

City

State

ZIP

Email Address

Phone Number

Reference 3

First Name

Last Name

Title

Address Line 1

Address Line 2

City

State

ZIP

Email Address

Phone Number

Reference 4

Title

Address Line 1

Address Line 2

City

State

ZIP

Email Address

Phone Number

Authorization

Please Read Carefully Before Signing

I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that misrepresentation or omission of facts is cause for disqualification from further consideration for hire or for dismissal.

I authorize the references listed in this Application, including personal and employment references, to provide you with all information pertinent to this Application and I release all parties from liability for any damages that may result from the release of any information as a part of the employment verification process. In consideration for the Company’s review of this application, I authorize investigation of all statements contained in this application. My cooperation includes authorizing the Company to conduct, when requested, a pre-employment drug screen, and a criminal or credit history investigation. Additionally I authorize the Company, in consideration for the Company’s review of this application, to supply employment record, in whole or in part, and in confidence, to any government agency, or other party, with a legal or proper interest.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the Company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no promise or guarantee is binding upon the Company unless made in writing. Further, I understand that Iowa is an employment-at-will state, as such, my employment may be ended by either me or my employer at any time with or without cause. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company, and that, if employed, my employment is at will and that I have the right to terminate my employment at any time for any reason and that the Company retains the same right.

I understand and agree that upon the event of employment, I will be expected to be candid and cooperate fully with any and all investigative efforts undertaken by the Company to resolve any customer or monetary transactions.

I understand and agree that in accordance with Federal Law, I must provide proof of identity and proof of eligibility to work in this country upon the event of employment.

In the absence of a handwritten signature, I understand that clicking the checkbox below serves as a written signature for the purposes of this application.

Signature of Applicant I have read and agree with the text above.

Voluntary Self-Identification for Affirmative Action

Our company is an Affirmative Action/Equal Employment Employer and as such, we are required to collect and maintain information related to applicants in order to meet governmental recordkeeping and reporting requirements and to monitor the effectiveness of our outreach, recruitment, and other employment practices.

At this time, we are asking you to help us meet our obligations by providing the information listed on the following pages. Please note that the information will be used only in accordance with the provisions of applicable laws, executive orders, and regulations. Providing this information is voluntary and refusal to so will not result in any adverse treatment. The information you provide will be held in strict confidence except that:

Necessary management and supervisory personnel may be informed to ensure proper placement and to provide reasonable job accommodations; and
First aid and safety personnel may be informed to the extent appropriate, if the condition might require emergency treatment; and
Government officials investigating affirmative action program compliance may have access to reported information.

Thank you for your cooperation in this important initiative. First Security abides by the requirements of federal laws which prohibit discrimination of individuals with the following legally protected status: race, color, religion, sex, sexual orientation, gender identity, national origin, disability, and protected veterans. [Company name] also abides by affirmative action requirements to employ and advance in employment qualified individuals without regard to race and sex (per Executive Order 11246), disability
(per 41CFR 60-741.5(a), and protected veteran status (per 41CFR 60-300.5(a).

Gender, Ethnicity and Race Information

Gender

Male

Female

I choose not to disclose this information

Ethnicity

Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin regardless of race)

Not Hispanic or Latino (if not Hispanic, please address race below)

I choose not to disclose this information

Protected Veterans

The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran.

Disabled Veteran

A “disabled veteran” is one of the following:

A veteran of the U.S. military, ground, naval or air service who is entitled to
compensation (or who but for the receipt of military retired pay would be entitled to
compensation) under laws administered by the Secretary of Veterans Affairs; or

A person who was discharged or released from active duty because of a serviceconnected
disability.

Recently Separated Veteran

A “recently separated veteran” means any veteran during the three-year period
beginning on the date of such veteran’s discharge or release from active duty in
the U.S. military, ground, naval, or air service.

Active-Duty Wartime or Campaign Badge Veteran

An “active-duty wartime or campaign badge veteran” means a veteran who served
on active duty in the U.S. military, ground, naval or air service during a war, or in a
campaign or expedition for which a campaign badge has been authorized under
the laws administered by the Department of Defense.

Armed Forces Service

Medal Veteran An “armed forces service medal veteran” means a veteran who, while serving on
active duty in the U.S. military, ground, naval or air service, participated in a United
States military operation for which an Armed Forces service medal was awarded
pursuant to Executive Order 12985.

Select One:

I am a Protected Veteran

I am not a Protected Veteran

I choose not to disclose the information

If you are a disabled veteran, you may use the space below to tell us about:

Any special skills, knowledge, or abilities which may qualify you for positions within First Security Bank so that you can be considered for positions of that kind, and
Any reasonable accommodation that you may need because of a disability which would enable you to engage in the application process or perform the essential functions of the job properly and safely. This might include, but is not limited to, a change to application or work procedures, documents in an alternate format, sign language interpreter, or specialized equipment.

Additional Information

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least
every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

Autism
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or hard of hearing
Depression or anxiety
Diabetes
Epilepsy
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Intellectual disability
Missing limbs or partially missing limbs
Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Please check one of the options below:

Yes, I have a disability, or have a history/record of having a disability.

No, I don't have a disability, or a history/record of having a disability.

I don't wish to answer.

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