Application Form – Montgomery Bank

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Position(s) Applied For *

Date of Application *

How Did You Learn About Us?

Advertisement
Employment Agency
Relative
Inquiry
Friend
Other

If you check "Other" explain

Last Name *

First Name *

Middle Name

Address *

Street Address Address Line 2 City State ZIP Code

Phone *

Social Security Number *

Email

Best time to contact you at home is

a.m.
p.m.

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes
No

Have you ever filed an application with us before?

Yes
No

If Yes, give date

Have you ever been employed with us before?

Yes
No

If Yes, give date

Do any of your friends or relatives, other than spouse, work here?

Yes
No

Are you currently employed?

Yes
No

May we contact your present employer?

Yes
No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status

Yes
No

Proof of citizenship or immigration status will be required upon employment

Date available for work

What is your desired salary range?

Are you available to work

Full-Time
Part-Time
Temporary

Please indicate

Monday - Friday (Including Saturdays as required)
Other

Please indicate dates available

Are you currently on “lay-off” status and subject to recall?

Yes
No

Can you travel if a job requires it?

Yes
No

EDUCATION

Elementary School

Name and Address of School	Course of Study	Years Completed	Diploma Degree

High School

Name and Address of School	Course of Study	Years Completed	Diploma Degree

Undergraduate College

Name and Address of School	Course of Study	Years Completed	Diploma Degree

Graduate Professional

Name and Address of School	Course of Study	Years Completed	Diploma Degree

Other (Specify)

Name and Address of School	Course of Study	Years Completed	Diploma Degree

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States military

EMPLOYMENT EXPERIENCE

1. Employer

Dates Employed

From	To

Address

Telephone Number(s)

Hourly Rate/Salary - Starting

Hourly Rate/Salary - Final

Job Title

Supervisor

Reason for Leaving

Work Performed

Do you have 2nd Employer?

Yes
No

2. Employer

Dates Employed

From	To

Address

Telephone Number(s)

Hourly Rate/Salary - Starting

Hourly Rate/Salary - Final

Job Title

Supervisor

Reason for Leaving

Work Performed

Do you have 3rd Employer?

Yes
No

3. Employer

Dates Employed

From	To

Address

Telephone Number(s)

Hourly Rate/Salary - Starting

Hourly Rate/Salary - Final

Job Title

Supervisor

Reason for Leaving

Work Performed

Do you have 4th Employer?

Yes
No

4. Employer

Dates Employed

From	To

Address

Telephone Number(s)

Hourly Rate/Salary - Starting

Hourly Rate/Salary - Final

Job Title

Supervisor

Reason for Leaving

Work Performed

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

ADDITIONAL INFORMATION

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

SPECIALIZED SKILLS (CHECK SKILLS/EQUIPMENT OPERATED)

Terminal
PC/MAC
Spreadsheet
Word Processing
Other

Other

SPECIALIZED SKILLS

Production/ Teller Equipment	Other (list)

(CHECK SKILLS/EQUIPMENT OPERATED)

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants:

DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given.

Yes
No

REFERENCES

1. Name

Telephone number

Address

2. Name

Telephone number

Address

3. Name

Telephone number

Address

APPLICANT’S STATEMENT

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

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 employer.

eSignature *

Date

REQUEST FOR CRIMINAL RECORD CHECK

Through Missouri State Highway Patrol SHP-158D 9/93

Name *

First Middle Last

(maiden/alias)

Date of Birth *

Sex

Male
Female

Race *

Social Security No *

Complete Address *

I authorize the release of any criminal history record information to the requestor.

eSignature (Optional)

It is the responsibility of the requestor to inform the Central Repository of the records that are desired and to provide the information necessary to conduct the appropriate search. See reverse side for details.

PURPOSE

Employment
Child Care
Nursing Home
Home Health Care
Other Employment
Licensing
Other (specify)

If other explain

Consumer Credit Investigation Authorization

In compliance with the Fair Credit Reporting Act (FCRA) (12 CFR 222), the Fair and Accurate Credit Transaction Act of 2003 (FACT Act) (Public Law 108-159), and applicable state laws, I consent to Montgomery Bank obtaining a consumer credit report in connection with my application for employment or current employment.

I understand my signature below represents my voluntary authorization for Montgomery Bank, including its agents and representatives, to obtain a consumer credit report on me.

Applicant/Employee eSignature

SSN

Print Name

Date

Voluntary self-disclosure of personal disability

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 1. To help us measure how well we are doing, we are asking you to tell us if you have a disability or it 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 our employees to update their information every five years. You may voluntarily self-identify as having as 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
Schizophrenia
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
I DON’T WISH TO ANSWER

Your Name

Date

Voluntary Self-Identification of Disability

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Pease 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.

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 person 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.

MONTGOMERY BANK

OFCCP VEVRAA Self-Identification Form

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. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.

I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

DISABLED VETERAN
RECENTLY SEPARATED VETERAN
ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN
I am a protected veteran, but I choose not to self-identify the classifications to which I belong.
I am NOT a protected veteran.

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.

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.

It is the policy at the Bank to provide equal employment and advancement opportunities to all qualified individuals. To achieve this goal, the Bank is dedicated to taking affirmative action to employ and advance in employment, qualified disabled persons, disabled veterans, veterans of the Vietnam Era, and other eligible veterans, in compliance with Section 503 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974.

The Bank is committed to take voluntary, positive action in providing affirmative action and equal employment opportunity to disabled persons, disabled veterans, veterans of the Vietnam Era, and other eligible veterans. All personnel actions, including recruitment, hiring, training, and promoting persons in all job titles, will be administered without regard to disability, Vietnam Era veteran, or other eligible veteran status, and all employment decisions are based solely on valid job requirements.