Name (First) (Middle) (Last) Address. (City) (State) (Zip Code) (Home Phone Number) (Cell Phone Number) ( Address)
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- Alexandra Marshall
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1 Date Name (First) (Middle) (Last) Address (Number) (Street) (City) (State) (Zip Code) (Home Phone Number) (Cell Phone Number) ( Address) List previous addresses within last 5 years Are you over 18 years of age? Yes No If no, can you supply a work permit? Yes No Do you have the legal right to remain and work in the United States? Yes No NOTE: You will be required to submit proof of your identity and employment authorization as a condition of employment. Have you been employed here previously? Yes No If yes, when Do you have friends or relatives employed by us? Yes No If yes, who and what is their relation? Position Applied For Salary Requirement Available For: Full-Time Part-Time Date Available For Work If Part-Time, please state days/hours available How were you referred? News Ad Customer Employee Other In accordance with state and federal laws, Granite Bank provides equal employment opportunity. Employment decisions are made without regard to age, race, national origin, color, sex, sexual orientation, marital status, gender identity, physical or mental disability or veteran status.
2 GENERAL INFORMATION: Name by which you are known to references if different from present name Have you been convicted of a crime other than misdemeanors or summary offenses that has not been annulled? Yes No If yes, please explain the specific nature of the offense(s) and surrounding circumstances, including your age at the time of conviction and any rehabilitation NOTE: Conviction of a crime will not automatically result in your disqualification from consideration for employment. The seriousness of the crime, date of conviction, etc. will be considered in relation to the particular position(s) available or for which you have applied. Have you served in the US Armed Forces? Yes No If yes, when Please list any relevant training and/or education Please describe the skills you feel qualify you for employment with our organization: EDUCATION: Years Completed Degree Received High School: Name College: Name Other: Name EMPLOYMENT HISTORY: Please complete all requested information beginning with your most recent employer. You may also attach a resume. From To Employer Name Telephone Job Title Address Immediate Supervisor and Title Summarize position title and job responsibilities Reason for Leaving Hourly Rate/Salary May we contact your employer? Yes No Start $ per Ending $ per
3 From To Employer Name Telephone Job Title Address Immediate Supervisor and Title Summarize position title and job responsibilities Reason for Leaving Hourly Rate/Salary May we contact your employer? Yes No Start $ per Ending $ per From To Employer Name Telephone Job Title Address Immediate Supervisor and Title Summarize position title and job responsibilities Reason for Leaving Hourly Rate/Salary May we contact your employer? Yes No Start $ per Ending $ per REFERENCES: Please provide the names of three business references who would be in addition to present or past supervisors: Name Company Name Telephone Years Known PLEASE READ CAREFULLY I hereby certify that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and will be considered grounds for immediate discharge if discovered at a later date. I understand that this application for employment does not constitute an employment contract and that if hired, I will be an at-will employee, meaning that I can terminate my employment or the Bank can terminate my employment at any time, with or without cause or notice. I authorize you to conduct any necessary and reasonable investigation with respect to my application, including my financial and credit records, and release my former employers, Granite Bank and its officers, agents and employees from any liability from damage caused by giving and receiving information or opinions as to my employment or character. As a condition of employment, I understand that Granite Bank may perform random credit record checks. As a further condition of employment, I agree to conform to the policies and procedures of Granite Bank. Date Signature of Applicant
4 Applicant Information (Applicant should keep this form) Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed 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 years old,, or bankruptcies that are more than ten years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting 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-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit 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: FDIC 15 Braintree Hill Office Park Suite 100 Braintree, MA
5 CONSUMER/CREDIT REPORT AUTHORIZATION I understand that in connection with my application for employment and, if hired, during the course of my employment, a consumer report may be obtained for employment purposes. The consumer report may include, but not be limited to, information from credit checks, motor vehicle record checks, criminal history searches, education verifications, employment verifications and reference checks. In addition, I understand the Bank intends to obtain a credit report to be used in connection with the Bank s consideration of my application for employment. In the event that information from my credit report results in a decision by the Bank not to extend an offer of employment, I will be provided with a copy of my credit report and an FTC notice of rights form. As evidenced by my signature below, I authorize Granite Bank to obtain a consumer and credit report to be used in connection with the Bank s consideration of my application for employment. Date Applicant s Signature Applicant s Date of Birth Applicant s Social Security Number
6 GRANITE BANK APPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY EMPLOYER WE CONSIDER APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, OR ANY NON-JOB RELATED DISABILITY. EQUAL ACCESS TO PROGRAMS, SERVICE AND EMPLOYMENT IS AVAILABLE TO ALL PERSONS. THOSE APPLICANTS REQUIRING REASONABLE ACCOMMODATION TO THE APPLICATION AND/OR INTERVIEW PROCESS SHOULD NOTIFY THE INDIVIDUAL RESPONSIBLE FOR HUMAN RESOURCES. THIS APPLICATION WILL BE GIVEN EVERY CONSIDERATION, BUT ITS RECEIPT DOES NOT IMPLY THAT THE APPLICANT WILL BE EMPLOYED. APPLICATIONS WILL BE CONSIDERED FOR VACANCIES WHICH ARISE DURING THE 60 DAY PERIOD FOLLOWING SUBMISSION. APPLICANTS SHOULD COMPLETE AN UPDATED APPLICATION IF NOT CONTACTED AND/OR HIRED DURING THIS 60 DAY EVALUATION PERIOD. PLEASE COMPLETE THIS FORM CAREFULLY IN YOUR OWN HANDWRITING. REPLIES TO ALL QUESTIONS WILL BE HELD IN STRICTEST CONFIDENCE. IF YOUR ANSWERS OR STATEMENTS REQUIRE ADDITIONAL SPACE, OBTAIN SUPPLEMENTAL SHEETS FROM THE RECEPTIONIST. IN ORDER TO BE CONSIDERED FOR EMPLOYMENT, THIS APPLICATION MUST BE COMPLETED IN FULL. PLEASE INDICATE THE SPECIFIC JOB TITLE FOR WHICH YOU ARE INTERESTED IN BEING CONSIDERED. INDIVIDUALS WHO EXPRESS AN INTEREST IN ANY POSITION, OR A GENERIC TITLE WILL NOT BE CONSIDERED FOR EMPLOYMENT. THE BANK IS COMMITTED TO MAINTAINING A WORKPLACE FREE OF THE PROBLEMS ASSOCIATED WITH DRUG OR ALCOHOL ABUSE. AS SUCH, ALL APPLICANTS ARE REQUIRED TO UNDERGO TESTING AS PART OF THE PRE-EMPLOYMENT PROCESS. IF YOU CURRENTLY USE ILLEGAL DRUGS, WE SUGGEST THAT YOU NOT COMPLETE THE APPLICATION PROCESS. A POSITIVE DRUG TEST WILL RESULT IN DISQUALIFICATION FROM EMPLOYMENT OR WITHDRAWAL OF ANY EMPLOYMENT OFFER. POSITION SOUGHT: DATE:
7 GRANITE BANK APPLICANT DATA RECORD Applicants and Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap/disability, or any other legally protected status. We comply with government regulations, including affirmative action responsibilities where they apply. Solely to help us comply with governmental record keeping, reporting and other legal requirements, we request that you please fill out the Applicant Data Record. We appreciate your cooperation. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment. YOUR COOPERATION IS VOLUNTARY. PLEASE PRINT Date Position Applied For Name ( ) Phone Last First Middle Area Code Address Number Street City State Zip Code Referral Source: Advertisement Friend Relative Employment Agency Walk In Other CONFIDENTIAL INFORMATION VOLUNTARY SURVEY Various government agencies request statistical information regarding our hiring practices. Your cooperation in completing this form is completely voluntary. Any information gathered is strictly confidential and will not subject you to coercion or intimidation relating to your status. Failure to provide this information will not adversely affect your application. Thank you for your cooperation. Check One: Male Female Check one of the following Race/Ethnic Groups: Hispanic or Latino Other If other, check one of the following Race/Ethnic Groups: White Asian Native American Indian/Alaskan Native Black or African American Two or more Races Native Hawaiian or Other Pacific Islander If Native American Indian, check if any of the following are applicable: Formal member of a particular tribe Have a membership card issued by the tribe Have a Certificate of Degree of Indian Blood issued by the Bureau of Indian Affairs Are considered an American Indian in your community Used American Indian School or hospital
8 I am: 1. A Disabled Veteran Yes No 2. An Armed Forces Service Medal Veteran Yes No 3. A Recently Separated Veteran Yes No 4. An Active Duty Wartime or Campaign Badge (Other Protected) Veteran Yes No Definitions: 1. A Disabled Veteran means (i) 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 (ii) a person who was discharged or released from active duty because of a service-connected disability. 2. 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 (61 Fed. Reg. 1209) at 3. Recently Separated Veterans 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. 4. Active Duty Wartime or Campaign Medal (Other Protected) Veterans 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. For those with Internet access, the information required to make this determination is available at Information also may be obtained by sending an to helpdesk@vets100.com or by calling (301)
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