FSNB Employment Applications

EMPLOYMENT APPLICATION
In compliance with Federal and State equal employment opportunity laws, qualified applicants are
considered for all positions without regard to race, color, religion, sex, national origin, age, marital
status, veteran status, non-job related disability or any other protected group status.
This application will be given every consideration, but its receipt does not imply that the applicant will
be employed. Each question should be answered in a complete and accurate manner as no action can
be taken on this application until all questions have been answered.
PLEASE ANSWER EVERY QUESTION. PRINT AND USE INK.
NAME (FIRST, MIDDLE, LAST)
ADDRESS (STREET, CITY, STATE, ZIP)
SSN:
DATE
TELEPHONE NUMBER
LENGTH OF TIME AT PRESENT ADDRESS?
LIST PREVIOUS ADDRESSES, IF ADDRESS CHANGED DURING THE PAST 5 YEARS
ADDRESS (STREET, CITY, STATE, ZIP)
DATE
DATE
ADDRESS (STREET, CITY, STATE, ZIP)
FROM:
DATE
TO:
DATE
ADDRESS (STREET, CITY, STATE, ZIP)
FROM:
DATE
TO:
DATE
ADDRESS (STREET, CITY, STATE, ZIP)
FROM:
DATE
TO:
DATE
ADDRESS (STREET, CITY, STATE, ZIP)
FROM:
DATE
TO:
DATE
FROM:
TO:
Type of work desired
Date available for work
FROM HERE ON, PLEASE WRITE IN YOUR NORMAL HANDWRITING
Salary requirements
How where you referred to us?
If you are under 18 years old, can you provide a
work permit if necessary?
Yes
1 of 5
No
Are you eligible to work in the US?
Yes (Proof Required)
No
EDUCATION
High School or Preparatory:
ADDRESS (CITY AND
STATE)
NAME
MAJOR COURSE
OR SUBJECT
DEGREE
LAST YEAR COMPLETED
(MARK ONE)
1
2
3
4
1
2
3
4
Business School:
ADDRESS (CITY AND
STATE)
NAME
MAJOR COURSE
OR SUBJECT
DEGREE
LAST YEAR COMPLETED
(MARK ONE)
1
2
3
4
1
2
3
4
College:
ADDRESS (CITY AND
STATE)
NAME
MAJOR COURSE
OR SUBJECT
DEGREE
LAST YEAR COMPLETED
(MARK ONE)
1
2
3
4
1
2
3
4
Graduate Work:
ADDRESS (CITY AND
STATE)
NAME
MAJOR COURSE
OR SUBJECT
IF YOU DID NOT GRADUATE, WHY DID YOU LEAVE SCHOOL OR COLLEGE?
ARE YOU PLANNING TO PURSUE FURTHER STUDIES?
No
Yes
Day School
Night School
IF SO, WHEN, WHERE AND WHAT COURSES?
2 of 5
DEGREE
LAST YEAR COMPLETED
(MARK ONE)
1
2
3
4
1
2
3
4
GENERAL INFORMATION
List any special skills or training (languages, machine operation, etc.) which you feel would benefit you for the
position for which you are applying.
Word Processing
Date Entry
10-Key Calculator
Database
Special Software packages:
OFFICE
SKILLS
Programming Languages:
Languages Skills:
Other:
Have you been employed here previously?
No
Have you ever applied here before?
Yes When?
No
Yes When?
Do you have a relative currently working at FSNB or one of its affiliate Companies?
No
Yes If yes, name, place of work and relationship:
Have you ever been convicted of a criminal offense involving dishonesty or breach of trust (include but not
limited to robbery, embezzlement, forgery, perjury, tax evasion, etc.)? If so please explain below:
3 of 5
EMPLOYMENT RECORD
Starting with present or most recent, list all previous employers. Include self-employment, summer and part-time
jobs. If you need more space, please continue on a separate sheet.
COMPANY NAME AND PHONE NUMBER
DATES EMPLOYED
ADDRESS (STREET, CITY, STATE)
POSITION AND DUTIES
SUPERVISOR
SALARY
FROM:
STARTING:
TO:
LEAVING:
COMPANY NAME AND PHONE NUMBER
DATES EMPLOYED
ADDRESS (STREET, CITY, STATE)
POSITION AND DUTIES
SUPERVISOR
SALARY
FROM:
STARTING:
TO:
LEAVING:
COMPANY NAME AND PHONE NUMBER
DATES EMPLOYED
ADDRESS (STREET, CITY, STATE)
POSITION AND DUTIES
SALARY
STARTING:
TO:
LEAVING:
DATES EMPLOYED
ADDRESS (STREET, CITY, STATE)
POSITION AND DUTIES
SALARY
STARTING:
TO:
LEAVING:
IF YOU ARE PRESENTLY EMPLOYED, WHY DO YOU DESIRE TO CHANGE YOUR POSITION?
4 of 5
Yes
REASON FOR LEAVING
SUPERVISOR
FROM:
IF YOU ARE EMPLOYED, MAY WE CONTACT YOUR PRESENT EMPLOYER?
REASON FOR LEAVING
SUPERVISOR
FROM:
COMPANY NAME AND PHONE NUMBER
REASON FOR LEAVING
No
REASON FOR LEAVING
Military:
Have you ever served in the military?
Yes
No
Service Branch_________________________________ Date entered_____________________________
Date Separated_________________________________ Final Rank_______________________________
Disabled Veteran: 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 service-connected disability.
Active Wartime or Campaign Badge: 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. See attached list.
Armed Forces Service Medal 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.
Recently Separated 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.
I am a protected veteran, but I choose not to self-identify the classifications to which I belong.
I am NOT a protected veteran.
PLEASE READ BEFORE SIGNING: If you have any questions regarding the statement below, please
direct your questions to the employment interviewer.
In the event of my employment to a position in the Bank, I will comply with all rules and regulations as
set forth in the Bank’s policy manual or other communications distributed to all employees.
Additionally, I authorize the Bank to supply my employment record in whole or in part, in confidence, to
any prospective employer, government agency, or other party, with a legal and proper interest.
I certify that all statements made by me on this application are true and complete to the best of my
knowledge and understand that misrepresentation or omission of facts called for is cause for dismissal.
I also understand and agree that my employment is for no definite period and may, regardless of the
date of payment of wages and salary, be terminated at any time without any previous notice.
I hereby acknowledge that I have read the above statement and understand the same.
_________________________________
Signature of Applicant**
_______________________________
Date
**By signing this Electronic Signature, I agree that my electronic signature is the legally binding equivalent to my
handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten
signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic
signature is not legally binding….
5 of 5
Authorization and Consent for Release of Credit and Background Information
I authorize Fort Sill National Bank (FSNB) to procure consumer and criminal/police reports and understand that they
may contain information about my credit worthiness, credit standing, credit capacity, character, general reputation,
personal characteristics, mode of living or criminal record. I authorize and instruct any person or agency contacted by
FSNB to participate or conduct inquiries at its request, to compile information, and to furnish any information obtained as
a result of such inquiries. I further authorize FSNB, in its sole discretion, to furnish copies of this authorization and my
application to any person(s) and/or consumer reporting agency(ies) in connection with the above purposes. This
authorization in original or copy form shall be valid for my term of employment from the date indicated under my
signature.
ADDITIONAL STATE LAW NOTICES
If you are a California applicant, please also note:
CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by the
consumer reporting agency (CRA) during normal business hours. You may also obtain a copy of this file, upon
submitting proper identification and paying the costs of duplication services, by appearing at the CRA's offices in
person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the
file by telephone, upon submitting proper identification. The CRA has trained personnel available to explain your file
to you, including any coded information. If you appear in person, you may be accompanied by one other person,
provided that person furnishes proper identification.
California and Oklahoma applicants only: You will be provided with a free copy of any consumer reports or
investigative consumer reports obtained on you if you check the box below.
I wish to receive a free copy of the report.
____________________________
Print Name
____________________________
Signature
____________________________
Street Address
____________________________
Social Security Number
____________________________
____________________________
City, State, ZIP
Date
____________________________
E-Mail Address
Fair Credit Reporting Act Disclosure
The Fair Credit Reporting Act. 15 U.S.C. § 1681 et seq., permits an employer to obtain a consumer report from a
consumer reporting agency, regarding its employment applicants or current employees to assist it in making
employment-related decisions. The consumer report may include such information which bears on your credit
worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, mode of living or
criminal record. However, an employer must secure the prospective or current employee's authorization in writing
before it may request a consumer report about them. FSNB obtains consumer reports for employment purposes.
I hereby acknowledge that I have read, received and agree to the above Fair Credit Reporting Act Disclosure.
____________________________
Signature
6 of 7
____________________________
Date
Memorandum for: Employees
From: Human Resources Dept.
Subject: Request for EEO Information
This company is a government contractor. As a result of this coverage, we must comply with Federal and State Equal Employment Opportunity
record keeping and reporting requirements. To respond to these obligations, we must request the following information. PLEASE NOTE:
Submission of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse action. The information you submit
will be kept CONFIDENTIAL, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled
veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if
you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the
Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed
Name: ___________________________________
Job Title: _____________________________
Male
Female
Race/Ethnicity -Please choose one of the following:
American Indian or Alaskan Native: A person having origins in any of the peoples of North and South America (including Central
American).
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black racial groups of Africa.
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Two or More Races: A person having origins in two or more of the above classifications
Military service:
As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year
identifying the number of our employees belonging to each specified “protected veteran” category. It would also assist us if you tell us about
any special methods, skills and procedures which you may have. If you believe you belong to any of the categories of protected veterans listed
below, please indicate by checking the appropriate box.
If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to
perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is
customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making
reasonable accommodations for your disability.
Submission of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse treatment. The information provided
will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.
Disabled Veteran: 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 service-connected disability
Active Wartime or Campaign Badge: 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. See attached list
Armed Forces Service Medal 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
Recently Separated 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.
I am a protected veteran, but I choose not to self-identify the classifications to which I belong
I am NOT a protected veteran.
Signature: _________________________________
7 of 8
Submit by Email
Date: ___________________________________________
Print Application
Campaign Badge Veterans
CAMPAIGN/EXPEDITION
DATES
ORGANIZATIONS PARTICIPATING
START
END
ARMY
NAVY
09/08/39
05/09/45
05/09/45
05/09/45
09/03/45
07/07/37
09/02/45
06/27/50
03/24/99
06/11/99
04/04/99
04/04/99
03/24/99
04/05/99
03/31/99
06/11/99
04/01/99
05/09/45
05/08/45
05/08/45
05/09/45
08/02/90
07/04/65
12/07/41
07/27/55
10/02/90
05/05/55
04/27/52
09/07/39
04/01/57
07/27/54
06/10/99
To Be Det
09/01/99
07/10/99
07/20/99
06/24/99
07/08/99
To Be Det
11/01/99
10/25/54
10/25/55
10/02/90
10/25/55
11/02/95
03/28/73
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
09/11/01
03/19/03
08/14/61
11/20/95
12/20/96
12/20/96
06/21/98
03/29/73
04/11/75
07/14/60
11/23/64
10/24/62
04/28/65
01/01/81
09/11/01
10/23/83
Present
Present
06/01/63
12/20/96
06/20/98
06/20/98
Present
08/15/73
04/13/75
09/01/62
11/27/64
06/01/63
09/21/66
02/01/92
Present
11/21/83
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AIR FORCE
CORP
GUARD
X
X
X
X
X
X
Campaign or Services Medals
American Defense Service
Army Occupation of Austria
Army Occupation of Berlin
Army Occupation of Germany
Army Occupation of Japan
China Service
China Service Medal (Extended)
Korean Service
Kosovo (KCM) Operation Allied Force
Kosovo (KCM) Operation Joint Guardian
Kosovo (KCM) Operation Allied Harbor
Kosovo (KCM) Operation Sustain Hope/Shining Hope
Kosovo (KCM) Operation Noble Anvil
Kosovo (KCM) Operation Task Force Hawk
Kosovo (KCM) Operation Task Force Saber
Kosovo (KCM) Operation Task Force Falcon
Kosovo (KCM) Operation Task Force Hunter
Navy Occupation of Trieste
Navy Occupation of Austria
Navy Occupation of Berlin
Navy Units of the Sixth Fleet
Southwest Asia Service Medal (Desert Shield/Storm)
Vietnam Service Medal (VSM)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Armed Forces Expeditionary Medal (AFEM)
Afghanistan (Operations enduring Freedom (OEF)
Afghanistan (Operations enduring Iraqi Freedom (OIF)
Berlin
Bosnia
Bosnia Operations (Joint Endeavor)
Bosnia Operations (Joint Guard)
Bosnia Operations (Joint Forge)
Cambodia
Cambodia Evacuation (Eagle Pull)
Congo
Congo
Cuba
Dominican Republic
El Salvador
Global War on Terrorism
Grenada (Operation Urgent Fury)
CAMPAIGN/EXPEDITION
DATES
ORGANIZATIONS PARTICIPATING
START
END
ARMY
NAVY
AIR FORCE
CORP
GUARD
09/16/94
01/01/97
12/31/98
09/11/01
03/19/03
10/01/66
04/19/61
07/01/58
06/01/83
04/12/86
05/15/75
12/20/89
07/24/87
08/02/90
12/01/95
12/01/95
12/01/95
11/11/98
12/16/98
08/23/58
12/05/92
08/23/58
05/16/62
07/01/58
04/29/75
03/31/95
Present
12/31/02
Present
Present
06/30/74
10/07/62
11/01/58
12/01/87
04/17/86
05/15/75
01/31/90
08/01/90
01/02/92
Present
02/15/97
Present
12/22/98
12/22/98
06/01/63
03/31/95
01/01/59
08/10/62
07/03/65
04/30/75
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
01/03/61
11/21/79
12/08/78
08/20/82
08/05/90
01/20/86
04/01/80
02/01/90
02/01/87
04/07/94
05/16/62
10/23/62
10/20/81
06/06/79
05/31/83
02/21/91
06/27/86
12/19/86
06/13/90
07/23/87
04/18/94
08/10/62
Armed Forces Expeditionary Medal (AFEM) CONT'D.
Haiti (Operation Uphold Democracy)
Iraq (Northern Watch)
Iraq (Desert Spring)
Iraq (Enduring Freedom (OEF)
Iraq (Iraqi Freedom (OIF)
Korea
Laos
Lebanon
Lebanon
Libyan Area (Eldorado Canyon)
Mayaquez Operation
Panama (Just cause)
Persian Gulf (Earnest Will)
Persian Gulf
Persian Gulf (Southern Watch)
Persian Gulf (Vigilant Sentinel)
Persian Gulf Interception Operation
Persian Gulf Operation (Operation Desert Thunder)
Persian Gulf Operation (Operation Desert Fox)
Quemoy and Matsu Islands
Somalia (Restore Hope)
Taiwan Straits
Thailand
Vietnam and Thailand
Vietnam Evacuation
Navy Expeditionary Medal and Marine Corp Expeditionary Medal
Cuba
Indian Ocean/Iran
Iranian/Yemen/Indian Ocean
Lebanon
Liberia (Sharp Edge)
Libyan Area
Panama
Panama
Persian Gulf
Rwanda (Distant Runner)
Thailand
8 of 8
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X