Print Clearly/Complete Fully Position applied for: Date of application


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NamePrint Clearly/Complete Fully Position applied for: Date of application
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Application for Employment

As an Equal Opportunity Employer, this organization does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, pregnancy, age (40+), military status, ancestry, genetic information, veteran status, or any other characteristics protected by federal, state, or local laws.

Print Clearly/Complete Fully



Position applied for: Date of application

How were you referred to us?  Newspaper ad  School  On my own


 Current Employee  Agency  Other
Name_______________________________________________________________________________________________
Address

Number Street City State Zip Code



Home Telephone Business Phone

(Area Code) Number (Area Code) Number

How long have you lived at present address?
Are you over the age of 18?  Yes  No
Do you wish to work:  Full Time  Part Time  Summer
If part time, specify hours or days:
What is your desired hourly wage or salary?
Date available for work:
Do you have any commitments to another employer that might affect your employment with us?
Are you currently bound by a noncompetitive agreement?  If so, please explain.___________________________________
___________________________________________________________________________________________________
Have you previously applied for employment here?  Yes  No If yes, when?
Have you previously been employed by this company?  Yes  No If yes, when?
Are any of your relatives employed here?  Yes  No If yes, please list name and relation

Are you legally authorized to work in the United States (Proof of identity & eligibility will be required upon employment.)  Yes  No
Will you now, or in the future, require sponsorship for employment Visa status (e.g., H-1B status)?

 Yes  No

Have you been convicted of a felony or misdemeanor other than moving traffic violations (even if expunged)? (Conviction will not necessarily preclude employment.)  Yes  No


If yes, then for each conviction, provide the date of conviction, nature of offense, and city/state of conviction:


Education

School

Name, City and State

Major Course of Study

Circle Highest Year Completed

Diploma or Degree Received

High School







9

10

11

12

[ ] Yes

[ ] No


College








1


2


3


4

[ ] Yes

[ ] No

Type

Other (Specify)








1


2


3


4

[ ] Yes

[ ] No

Type



Employment History

List below all present and past employment, beginning with your most recent. (Please use additional sheets, if necessary.)

Employer Name:

Phone: ( )

Address:

Supervisor Name(s):

Job Title:

Starting Salary: $ Ending Salary: $

Responsibilities:

Employment Dates (give month and year):

Reason for Leaving:

May we contact the employer for a reference?

YES

NO







Employer Name:

Phone: ( )

Address:

Supervisor Name(s):

Job Title:

Starting Salary: $ Ending Salary: $

Responsibilities:

Employment Dates (give month and year):

Reason for Leaving:

May we contact the employer for a reference?

YES

NO







Employer Name:

Phone: ( )

Address:

Supervisor Name(s):

Job Title:

Starting Salary: $ Ending Salary: $

Responsibilities:

Employment Dates (give month and year):

Reason for Leaving:

May we contact the employer for a reference?

YES

NO





List any other experiences, skills or qualifications which you feel would qualify you to work for our company. However, please exclude those that may disclose race, color, religion, sex, national origin, sexual orientation, gender identity, disability, protected veteran status, pregnancy, age (40+), military status, ancestry, genetic information, or any other characteristic protected by federal, state, or local laws.

READ CAREFULLY BEFORE SIGNING



In signing and submitting this application for employment to you, Farmers Bank & Trust, I clearly understand and agree:


    1. I certify that the information contained in this application is correct and complete to the best of my knowledge and understand that any omission, misrepresentation or falsification of information made herein or in any interviews is grounds for refusal to employ me or my dismissal if I am employed.

    2. I authorize the references listed above, school and current and past employers to give Farmers Bank and Trust any and all information concerning my previous employment and any information they may have, personal or otherwise, and I release all parties for all liability for any damage or claim that may result from furnishing the same to the Corporation.

    3. Any employment offer is contingent upon the following: (a) my providing, within 3 days after my first day of employment, valid proof of my identity and eligibility to work in the United States; (b) my consent for the employer to obtain consumer reports about me as part of its background check process and the employer’s satisfaction with the results of such background checks.

  1. If I am employed, I agree to abide by the rules, regulations and policies of Farmers Bank & Trust, and my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Corporation or myself, for any reason not prohibited by law.

  2. I understand that no representative of Farmers Bank & Trust, other than the President of the Corporation, has any authority to enter into any agreement for employment for any specified period of time, or make any agreement contrary to the foregoing.

  3. This application shall be considered active only for 90 days from today’s date. If I still desire a position with the employer after this application expires, it will be my responsibility to submit a new application.



Date:

Signature of Applicant


References


List name and telephone number of three business/work references that are not related to you. If not applicable, list three school or personal references that are not related to you.

Name

Telephone

Years Known


Invitation to Self-Identify



Name:
Position:
Date:

Farmers Bank and Trust (FBT) is a Federal contractor and an Equal Opportunity Employer. FBT is subject to Executive Order 11246, which requires government contractors to take affirmative action to ensure that equal opportunity is provided in all aspects of their employment. In addition, we are subject to Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment protected veterans. In order to comply with these laws, FBT invites applicants to voluntarily self-identify their gender, race/ethnicity and protected veteran status. FBT does not discriminate on the basis of race, religion, color, sex, sexual orientation, gender identity, age, protected veteran status, non-disqualifying physical or mental disability, national origin, genetic information, or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need.
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
Check one of the following:
Male
Female
I choose not to self-identify

Check one of the following race/ethnic groups defined on the following page:
Hispanic or Latino
White (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
American Indian or Alaska Native (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)
I choose not to self-identify

Check one of the following:
I identify as one or more of the classifications of protected veterans as defined on the following page
I am not a protected veteran.
I choose not to self-identify

Personal and Confidential

This page contains sensitive information, store in secure "Affirmative Action Forms" files, separately from personnel records.
Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.



Ethnicity and Race Definitions





  • Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.




  • White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.




  • Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.




  • Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.




  • Asian (Not Hispanic or Latino) - 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.




  • American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.




  • Two or More Races (Not Hispanic or Latino) – A person who identifies with more than one of the above five races.


Protected Veteran Definitions





  • Disabled Veteran - 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 service-connected disability.

  • Recently Separated Veteran - 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 - 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 - 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.



Voluntary Self-Identification of Disability



Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017

Page 1 of 2



Why are you being asked to complete this form?


Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.


How do I know if I 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:



Blindness Deafness Cancer Diabetes Epilepsy

Autism Cerebral palsy HIV/AIDS

Schizophrenia Muscular dystrophy

Bipolar disorder Major depression

Multiple sclerosis (MS) Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder

Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation)




Please check one of the boxes below:






YES, I HAVE A DISABILITY (or previously had a disability) NO, I DON’T HAVE A DISABILITY

I DON’T WISH TO ANSWER
Your Name Today’s Date


Voluntary Self-Identification of Disability
Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017

Page 2 of 2



Reasonable Accommodation Notice


Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.


REVISED 8/1/16







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