APPLICATION FOR EMPLOYMENT

Transcription

1 APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer, M/F/Disabled/Vets PERSONAL INFORMATION (Please Print) 4801 Kennedy Avenue Cincinnati, OH (513) Fax (513) or NAME (Last) (First) (Middle Initial) Date ADDRESS (Street) (City) (State) (Zip) TELEPHONE NUMBER ( ) SOCIAL SECURITY NUMBER Are you 18 years of age or older? Yes No Have you ever been convicted of any misdemeanor or felony (this includes, without limitation, pleading guilty, pleading no contest, or having a finding of guilt)? (Conviction will not necessarily disqualify your application from consideration.) Yes No If yes, where, for what, and give dates: Type of Position Applying for: (Describe) Full-Time Part-Time Temporary Salary or Rate of Pay Desired? Date available to start work? Will you work overtime hours? Yes No Do you have a reliable means of transportation to and from work? Yes No Were you referred by a current employee? Yes No If yes, who? Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? (Job description and essential job function sheet are available upon request.) Yes No Please list below three persons you have known for at least one year (exclude former employers and relatives). Name and Occupation Address Phone Number Page 1 of 6

2 Type of School High School Name and Address EDUCATIONAL BACKGROUND Course of Study Did you graduate? List Degree or Diploma College Graduate School Business or Trade Other Date, Month and Year From: To: From: To: From: To: From: To: WORK HISTORY (LIST MOST RECENT EMPLOYER FIRST) Employer s Name, Address, Phone Supervisor s Name. Address, Phone Job Title and Duties Start Salary End Reason for Leaving Are you known to schools/references/employers by another name? Yes No If yes, please indicate the name(s): List any special skills or training you feel we should be aware of in considering your application: Can you type? Yes No W.P.M. Computer Program Experience: MS Office Excel Access Windows Other Office Equipment Experience: Copier Fax Calculator Page 2 of 6

3 APPLICANT STATEMENT 1. My signature authorizes Cinfed Credit Union or its authorized agents to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process, including without limitation, information concerning my employment positions, law enforcement record, driving record, and educational background. I hereby authorize all persons, companies or other entities connected with any such informational request, including without limitation, current or prior employers and law enforcement agencies to provide any and all information they may have regarding me or my employment. I release and agree to indemnify Cinfed Credit Union its authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of such investigation, including without limitation any liability for furnishing information or for taking any action based on the information provided. 2. I hereby certify that all responses set forth during my employment application process are true and complete. I understand and agree that any falsification, misrepresentation, or omission either on the employment application form or in my responses to questions asked during the interviewing or examination process may disqualify me from further consideration for employment, or if employed by Cinfed Credit Union, will subject me to immediate termination, whenever the falsification or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope. 3. I understand that a drug screen may be required before and during my employment. In addition, I authorize a medical examination, including a drug and/or alcohol screen, by an examiner selected by Cinfed Credit Union if I am made a contingent offer of employment. I release and agree to indemnify Cinfed Credit Union, its authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of any medical examination or drug/alcohol screen or for the taking of any action based on the results of any medical examination or drug/alcohol screen. 4. I agree and consent that Cinfed Credit Union may inspect any Cinfed Credit Union property at any time and for any reason, without notice. This property includes, without limitation, work stations, computers, offices, desks, lockers, voice mail, and filing cabinets. Additionally, I agree and consent that any personal items I bring onto Cinfed Credit Union premises are subject to inspection at any time and for any reason, without prior notice. 5. I understand and agree if I am employed by Cinfed Credit Union, my employment is at-will so that I may terminate my employment at any time and for any or no reason. Likewise, the Company can terminate my employment at any time and for any or no reason. I also understand and agree that nothing contained in Cinfed Credit Union employment application or in the granting or conducting of an interview or anything set forth in any oral or written statement, communication, or policy now or in the future constitutes or creates or is intended to constitute or to create a contract or promise between me and Cinfed Credit Union for employment, hours of work, or for the providing of benefits. Moreover, I acknowledge that Cinfed Credit Union may modify, revoke, suspend, terminate or change any or all of its plans, policies, or procedures at any time, without prior notice. No promises or guarantees regarding employment, hours of work, or for the providing of benefits have been made to me. I further understand and agree that no such promise or guarantee is binding on Cinfed Credit Union unless it is in writing signed by me and the President of the Company and that document states that the employment relationship is not at-will and details the specific promise or guarantee. Applicant s Signature Date v2 Page 3 of 6

4 4801 Kennedy Avenue Cincinnati, OH (513) Fax (513) or FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION FORM DISCLOSURE Cinfed Credit Union, in accordance with the amended Fair Credit Reporting Act ( FCRA ), is advising you that it may obtain Consumer Reports from a Consumer Reporting Agency ( CRA ) about you when considering your application for employment, when deciding whether to continue your employment (if you are hired), and when making other employment-related decisions concerning you. Those Consumer Reports, as defined in the FCRA, may include information concerning your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. Cinfed Credit Union may obtain Investigative Consumer Reports from a CRA which may be obtained through personal interviews with your neighbors, friends or associates who may have knowledge concerning your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. You may request disclosure of the nature and scope of the investigation in writing within a reasonable period of time. Cinfed Credit Union may rely on any or all of the above-referenced information when making an employment decision that directly affects you. If Cinfed Credit Union contemplates making an employment decision that adversely affects you based, in whole or in part, upon information obtained from a CRA, you will be provided additional notices and information. AUTHORIZATION By signing below, I hereby voluntarily authorize Cinfed Credit Union or its authorized agents, to conduct a thorough investigation of me, including without limitation, obtaining Consumer Reports, including Investigative Consumer Reports and medical information, about me from a CRA and to consider the Consumer Reports when making decisions regarding my employment. Those Consumer Reports, as defined in the FCRA, may include any or all of the following information concerning my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. The Reports may be obtained through personal interviews with my neighbors, friends or associates. Signature Date Full Name [Please print] v1 Page 4 of 6

5 EQUAL EMPLOYMENT OPPORTUNITY INFORMATION FORM Cinfed Credit Union is an equal opportunity employer that is committed to a program of recruitment of females, minority group members, individuals with disabilities, and qualifying veterans. In order to comply with governmental reporting requirements, we request that you supply the information below. This information is voluntary and will in no way effect the processing of your application or your consideration for employment. This form should be submitted with the employment application, but will be processed separately and used for statistical purposes only. Please fill in the information requested and check all items that apply to you. Thank you for your cooperation. APPLICANT S NAME: DATE: POSITION APPLIED FOR: GENDER: Male Female Hispanic or Latino If not Hispanic or Latino: White (Not Hispanic or Latino) Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. Black or African American (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) Persons having origins in any of the black racial groups of Africa. Persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) Persons having origins in any of the original peoples of the Far East, Southeast Asia, or Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam Native Indian or Alaskan Native (Not Hispanic or Latino) Persons having origins in any of the original peoples of North and South America, (including Central America) and who maintain tribal affiliation or community recognition. Two or More Races (Not Hispanic or Latino) All Persons who identify with more than one of the above races, excluding those who identify themselves as Hispanic or Latino. [ ] I identify as one or more of the classifications of Protected Veteran listed on Page Two [ ] I am not a Protected Veteran Page 5 of 6

6 Cinfed Credit Union is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows: A disabled veteran is one of the following: o o 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. 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. 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. 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 Protected veterans may have additional rights under USERRA the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at USA-DOL. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box on Page 1. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Page 6 of 6

7 APPLICANT AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION, as a condition of employment, and/or continued employment, that all applicants consent to and authorize a verification of the information submitted on their application or resume. Please read this statement carefully. I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be considered as cause for possible dismissal. This release and authorization acknowledges that this Company may now, or at any time while I am employed or representing the company, conduct a verification of my education, employment history, credit history, and/or motor vehicle records. In addition this company may contact personal references, require that I provide a urine specimen or hair strands to be tested for the presence of drugs or alcohol, and receive any criminal history record information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency in any state, and/or other information as deemed necessary to fulfill the job requirements. Also, if an offer of employment has been made, I authorize review of my worker s compensation claim history. I authorize Employment Screening Associates and any of its agents and/or employees to disclose verbally and in writing the results of this verification process to the designated authorized representatives of this Company. The results will be used to determine employment eligibility under this Company's employment policies. Under no circumstances will ESA provide or disclose any information regarding your credit history. We do not share, disclose or sell any information that can be used to authenticate your identity such as your Social Security Number, Date of Birth or Mother s Maiden Name. I have read and understand this release and consent, and I authorize the background verification. I authorize persons, schools, current and former employers, and other organizations and Agencies to provide Employment Screening Associates with all information that may be requested, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original. I do hereby agree to forever release and discharge this Company, its agent, Employment Screening Associates, and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on information obtained by my prospective employer, and to receive, upon written request, a disclosure of the public record information and of the nature and scope of the investigative report. If I am a resident of Minnesota, California or Oklahoma only and would like a copy of the investigative report, I will check here. Please provide all requested information and provide addresses for the last seven- (7) years Applicant's Name: FIRST MIDDLE LAST Maiden Or Other Name(s) Current Address - Street, City, State, Zip Previous Address - City, State, Zip Previous Address - City, State, Zip How Long How Long How Long Social Security Number Date of Birth (for confirmation of ID only) Drivers License Number State Name - exactly as it appears on Driver's License Address Phone Number [ ] Yes [ ] No Authorization to contact present employer for reference? Signature Date Criminal History Have you been convicted or plead guilty to a crime in the last 7 years? [ ] Yes [ ] No Brief description of crime: Misdemeanor / Felony Please Circle Date: Place of conviction: City State County List additional convictions:

8 Para informacion en espanol, visite o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC ASummaryofYourRightsUndertheFairCreditReportingAct The federal Fair Credit Reporting Act(FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies(such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC Youmustbetoldifinformationinyourfilehasbeenusedagainstyou.Anyonewhousesa credit report or another type of consumer report to deny your application for credit, insurance, or employment ortotakeanotheradverseactionagainstyou musttellyou,andmustgiveyou the name, address, and phone number of the agency that provided the information. Youhavetherighttoknowwhatisinyourfile.Youmayrequestandobtainallthe information about you in the files of a consumer reporting agency(your file disclosure ). You will be required to provide proper identification, which may include your Social Security number.inmanycases,thedisclosurewillbefree. Youareentitledtoafreefiledisclosureif: a person has taken adverse action against you because of information in your credit report; youarethevictimofidentitytheftandplaceafraudalertinyourfile; your file contains inaccurate information as a result of fraud; you are on public assistance; youareunemployedbutexpecttoapplyforemploymentwithin60days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. Youhavetherighttoaskforacreditscore. Creditscoresarenumericalsummariesofyour credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real propertyloans,butyouwillhavetopayforit. Insomemortgagetransactions,youwillreceive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed

9 or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven yearsold,orbankruptciesthataremorethan10yearsold. Access to your file is limited. A consumer reporting agency may provide information about youonlytopeoplewithavalidneed usuallytoconsideranapplicationwithacreditor,insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. Youmustgiveyourconsentforreportstobeprovidedtoemployers.Aconsumerreporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-freephonenumberyoucancallifyouchoosetoremoveyournameandaddressfromthe lists these offers are based on. You may opt-out with the nationwide credit bureaus at Youmayseekdamagesfromviolators.Ifaconsumerreportingagency,or,insomecases,a user of consumer reports or a furnisher of information to a consumer reporting agency violates thefcra,youmaybeabletosueinstateorfederalcourt. Identity theft victims and active duty military personnel have additional rights. For more information, visit

10 States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact: TYPE OF BUSINESS: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates. b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau: 2. Totheextentnotincludedinitem1above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks CONTACT: a. Bureau of Consumer Financial Protection 1700GStreetNW Washington, DC b. Federal Trade Commission: Consumer Response Center FCRA Washington, DC (877) a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX b. State member banks, branches and agencies of foreign banks(other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN c. FDIC Consumer Response Center 1100 Walnut Street, Box#11 Kansas City, MO d. National Credit Union Administration Office of Consumer Protection(OCP) Division of Consumer Compliance and Outreach(DCCO) 1775 Duke Street Alexandria, VA Air carriers Asst. General Counsel for Aviation Enforcement& Proceedings Department of Transportation 400 Seventh Street SW Washington, DC Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 1925KStreetNW Washington, DC Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC Brokers and Dealers Securities and Exchange Commission 100FStNE Washington, DC Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations 9. Retailers, Finance Companies, and All Other Creditors Not Listed Above Farm Credit Administration 1501 Farm Credit Drive McLean, VA FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center FCRA Washington, DC (877)

11 Voluntary Self-Identification of Disability Why are you being asked to complete this form? Form CC-305 OMB Control Number Expires 1/31/2020 Page 1 of 2 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

12 Voluntary Self-Identification of Disability Reasonable Accommodation Notice Form CC-305 OMB Control Number Expires 1/31/2020 Page 2 of 2 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 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.