APPLICATION FOR EMPLOYMENT

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1 Main Branch Golden Heart Branch Chena Pump Branch Van Horn Branch Tok Junction 119 N. Cushman St Airport Way 470 Chena Pump Road 975 Van Horn Road Mile 1314 AK HWY Fairbanks, AK Fairbanks, AK Fairbanks, AK Fairbanks, AK Tok, AK APPLICATION FOR EMPLOYMENT Note to Applicant: This application must be completed in full (resumes are accepted but cannot be used as a substitute for any portion of this application). A separate application is required for each position for which you apply. Denali State Bank is an equal opportunity employer and considers applicants for all positions without regard to race, age, gender, religion, or any other legally protected status. Position Applied For: Type of work desired? Full-Time Part-Time Date Available for Work: Desired Pay Range: Personal Data First Name MI Last Name Date of Application: Address Telephone #: City State Zip Code 1. Are you authorized to work in the U.S. on an unrestricted basis? Yes No 2. Have you ever filed an application with us before? Yes No If yes, list date(s): 3. Have you ever been employed with us before? Yes No If yes, please describe: 4. Do you have any friends and/or relatives currently employed at Denali State Bank? Yes No If yes, please describe: **If referred by employee, please list name of referring employee 5. If necessary for the job, are you willing to travel? Yes No 6. If necessary for the job, are you able to work overtime? Yes No 7. If necessary for the job, are you able to provide a valid Alaska Driver s License? Yes No 8. Are you able to perform the essential functions of the position for which you re applying with or without reasonable accommodation? Yes No 9. Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation and position applied for will be taken into account. If yes, please describe on a separate sheet of paper. Have you ever been convicted of a felony? Yes No Rev

2 EMPLOYMENT HISTORY List your employment history for the past five years beginning with the most recent or present employer. Indicate name under which employed if different than this application. Complete application fully, do not indicate "see resume. You may exclude organizations which indicate race, color, religion, sex, national origin, disabilities or other protected status. If you need additional space, please attach a separate sheet of paper. Rev

3 EDUCATION High School Name and Address of School Course of Study Years Completed Diploma / Degree Undergraduate College Graduate/Professional Other (Specify) SKILLS Summarize special job-related skills and qualifications acquired from employment or other expertise. Examples include computer experience, WPM typing ability, 10-key ability, software knowledge, office equipment knowledge, etc. PROFESSIONAL AFFILIATIONS List professional, trade, business or civic activities and offices held. You may exclude those memberships which would reveal sex, race, religion, national origin, age, ancestry disability or other protected status. REFERENCES Please list three (3) professional references. Please do NOT list friends and/or family. 1. Name & Address Phone Number: 2. Name & Address Phone Number: 3. Name & Address Phone Number: Rev

4 APPLICANT S STATEMENT I certify that the statements in this application are true and complete. I understand that my employment is subject to the results of a consumer credit report and/or background check as it may concern credit, criminal, motor vehicle and other history. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I hereby give Denali State Bank permission to obtain reference and background information regarding my abilities and qualifications for employment and release reference sources from liability concerning information on reference. I understand that this application is not, nor is it intended to be, a contract of employment. 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 that proof of identity and legal authority to work in the United Sates must be provided at the time of hire. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Denali State Bank 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. I understand that I am required to abide by all rules and regulations of the employer. Applicant s Signature: Date: Rev

5 EEO-1 Voluntary Self Identification Form The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites applicants to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require that information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. As employers/government contractors, we also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive order 11246, Section 503 of the Rehabilitation Act of 1973, section 4212 of the Vietnam Era Veterans Readjustment Act of 1974 and Veterans Employment Opportunities Act (VEOA) of Application Date: MM/DD/YYYY Position Applied For: Name: Last Name First Name Middle Initial Date of Birth: Gender: Male Female MM/DD/YYYY Referral Source: Newspaper Ad Friend/Relative Company Website Employment Agency Other Website: RACE/ETHNICITY Please check one of the descriptions below corresponding to the ethnic group with which you identify Hispanic or Latino Black or African American Native Hawaiian or Other Pacific Islander White (Not Hispanic or Latino) Asian American Indian or Alaska Native Two or More Races (Not Hispanic or Latino) DISABLED WORKER Yes No An individual with a physical or mental impairment which substantially limits one or more of such person s major life activities; or any individual with a record of such impairment; or any individual regarded as having such on impairment. RECENTLY SEPARATED VETERAN Yes No 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. Date of Discharge or Release: ARMED FORCES SERVICE MEDAL VETERAN Yes No Any veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in the United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12895(61 FR 1209). DISABLED VETERAN Yes No Any veteran (A) 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 (B) a person who was discharged or released from active duty because of a service connected disability. OTHER PROTECTED VETERAN Yes No 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. (See Vet Guide Appendix A: Wars, Campaigns, and Expeditions of the Armed Forces since WWII Which Qualify for a Veterans Preference rhttp://www.opm.gov/staffingportal/vgmedal2.asp) Rev

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