Employment Application - Jonestown Bank & Trust Co.

Application for Employment

An Equal Opportunity Employer

We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity, disability, veteran status, or any other category protected by law.

Answer each question completely and accurately. No action will be taken on this application until you have answered all relevant questions. The following questions are not intended to imply illegal preferences or discrimination based upon non-employment related information.

Position(s) of Interest:

Are you seeking:

Full-timePart-time

Available start date:

First Name:

Middle Name:

Last Name:

Address

Street Address:

City:

State:

Zip Code:

Phone:

Social Security #:

Are you 18 years of age or older?:

YesNo

If hired, you will be required to submit proof of age.

If hired, can you furnish proof that you are eligible to work in the US?:

YesNo

Have you ever applied here before?:

YesNo

If yes, when?:

Were you ever employed here?:

YesNo

If yes, when?:

Have you ever been convicted of any law violation (except a minor traffic violation)?:

YesNo

If yes, give details.:

A 'yes' answer does not automatically disqualify you from employment, since the nature of the offence, date, and the job for which you are applying is also considered.

If you gain employment with JBT, do you plan on engaging in any other employment?:

YesNo

If yes, please explain.:

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Please provide months and years.

Employer 1

Name of Employer:

Supervisor:

Phone:

Street Address:

City:

State:

Zip Code:

Start Date:

End Date:

Pay Start:

Pay Final:

Reason for leaving:

Title and Duties:

Employer 2

Name of Employer:

Supervisor:

Phone:

Street Address:

City:

State:

Zip Code:

Start Date:

End Date:

Pay Start:

Pay Final:

Reason for leaving:

Title and Duties:

Employer 3

Name of Employer:

Supervisor:

Phone:

Street Address:

City:

State:

Zip Code:

Start Date:

End Date:

Pay Start:

Pay Final:

Reason for leaving:

Title and Duties:

Employer 4

Name of Employer:

Supervisor:

Phone:

Street Address:

City:

State:

Zip Code:

Start Date:

End Date:

Pay Start:

Pay Final:

Reason for leaving:

Title and Duties:

Education

List names and addresses of schools.

High School or GED:

High School or GED Address:

No. of Years Completed:

Diploma, Degree or Certificate:

DiplomaDegreeCertificate

College or University:

Major:

College or University Address:

No. of Years Completed:

Diploma, Degree, or Certificate:

DiplomaDegreeCertificate

Vocational or Technical:

Field of Study:

Vocational or Technical Address:

No. of Years Completed:

Vocational

Diploma, Degree or Certificate:

DiplomaDegreeCertificate

Special Skills

What skills or additional training do you have that are related to the position for which you are applying?:

What machines or equipment can you operate that are related to the position for which you are applying?:

For positions that require driving only:

Do you have a valid PA driver's license?:

YesNo

Driver's License Number:

Expiration Date:

Class of License:

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

Exclude labor organizations and memberships which reveal race, color, religion, sex, national origin, age, sexual orientation, gender identity, disability, veteran status or any other category protected by law.

References

Have you worked or attended school under any other names?:

YesNo

If yes, provide names:

Are you presently employed?:

YesNo

May we contact your present employer?:

YesNo

If yes, please provide the name and contact information:

Have you ever been terminated from employment or asked to resign?:

YesNo

If yes, please explain.:

Provide 3 references, not relatives or former employers.

Reference 1

Name:

Address:

Phone:

Reference 2

Name:

Address:

Phone:

Reference 3

Name:

Address:

Phone:

Affidavit

Please read each statement carefully before signing

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as condition of employment, if required.

I understand that this application or subsequent employment does not create a contract of employment or a guarantee of employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice.

By signing below, I acknowledge that I have read this document in its entirety and consent to the statements above.

Signature:

Date:

This application for employment will remain active for a limited time.

Employment Inquiry Release

In connection with your application for/continued employment with the Jonestown Bank & Trust Company, on their behalf, CBY Systems Inc. will make inquiries, including but not limited to, your consumer credit history, education, professional licensing, criminal history, driving history, your performance, experience and other qualities pertinent to your qualifications for employment, including reasons for termination of past employments. Such inquiries may include investigative consumer reports that relate to your character, general reputation, personal characteristics, or mode of living and are obtained by personal interviews with your neighbors, friends, associates, and others.

In compliance with the Fair Credit Reporting Act (FCRA), you are entitled to be informed if an offer of employment is withheld because of information obtained from CBY Systems Inc. and, in that event, upon your written request, CBY Systems Inc. will provide a copy of the consumer and/or investigative consumer reports we receive, information regarding the nature and scope of the investigation, and the FTC notice, "A Summary of Your Rights Under the Fair Credit Reporting Act." A copy of "A Summary of Your Rights Under the Fair Credit Reporting Act" is also linked from this Employment Inquiry Release.

Please complete and sign this form authorizing, without reservation, any party, including, but not limited to, employers, consumer reporting agencies, law enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by CBY Systems Inc. to furnish any or all of the above mentioned information, including consumer reports and/or investigative consumer reports. Your signature allows a photocopy or fax copy of this authorization to be as valid as the original.

Date of Birth:

Driver's License Number:

High School Graduation Date:

College Graduation Date:

Signature:

Date:

* Date of birth is requested only for the purposed of identification in obtaining accurate retrieval of records and it will not be used for discriminatory purposes.

Voluntary Self Identify Form

Jonestown Bank & Trust Co. is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as disabled, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please check all that apply (see below for definitions)

I do not wish to Self-Identify

Signature:

Date:

Other Explanation:

*Editor's note: According to 41 CFR 60-741-42, there are only two circumstances when an employer may ask a disabled applicant to self-identify on a pre-offer basis.

The invitation is made when the contractor actually is undertaking affirmative action for individuals with disabilities at the pre-offer stage; or
The invitation is made pursuant to a Federal, state or local law requiring affirmative action for individuals with disabilities.

**Editor's note: According to 41 CFR 60-250-41, there are only two circumstances under which an employer may ask applicants who are Special Disabled Veterans to self-identify on a pre-offer basis:

The invitation is made when the contractor actually is undertaking affirmative action for special disabled veterans at the pre-offer stage; or
The invitation is made pursuant to a Federal, state or local law requiring affirmative action for special disabled veterans.

EEOC Race/Ethnic Identification Categories

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, 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): All persons who identify with more than one of the above five races.
Individual with Disabilities: Defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, and individual with disability(s) is substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).
Veteran of the Vietnam-Era: Means a person who: (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in all cases; or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service connected disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in any other location.
Special 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 Department of Veterans' Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap or (ii) a person who was discharged or released from active duty because of a service connected disability.
Other Protected Veteran: Includes any veteran who served on active duty in the U.S. military, ground, naval or air service in war, campaign or expedition in which a campaign badge has been authorized under laws administered by the Department of Defense.
Recently Separated Veteran: Any veteran who served on active duty in the U.S. military, ground, naval or air service during the one year period beginning on the date of such veteran's discharge or release from active duty.
Armed Forces Service Medal Veteran: Includes any veteran who, while serving on active duty int he Armed Forces, participated in a United States military operation for which a services medal was awarded pursuant to Executive Order 12985.

Voluntary Self-Identification of 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 disabilities¹. 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 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

Signature:

Date:

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.

¹ 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.

Equal Opportunity Employment Notice

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Application for Employment

Work History

Education

Special Skills

References

Affidavit

Employment Inquiry Release

Voluntary Self Identify Form

EEOC Race/Ethnic Identification Categories

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do I know if I have a disability?

Reasonable Accommodation Notice

Questions or Comments

Ways to Contact JBT

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Business Checking

Business Savings & Loans

Business Team & Services

Personal Deposit

Personal Lending

Business Deposit

Business Lending

Application for Employment

Work History

Education

Special Skills

References

Affidavit

Employment Inquiry Release

Voluntary Self Identify Form

EEOC Race/Ethnic Identification Categories

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do I know if I have a disability?

Reasonable Accommodation Notice

Questions or Comments

Ways to Contact JBT