Application for Employment Valid for 90 days

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1 Application for Employment Valid for 90 days As a condition of employment, Liberty Bank and Trust Company requires that applicants consent to a criminal investigation, credit check, and undergo a drug-screening test. Positive test results from the drug screening process will disqualify applicants from further employment consideration. Liberty Bank reserves the right to request a criminal investigation, credit check, or drug screening test at any time during an employee's tenure with the Bank. (PLEASE PRINT) Last Name First Middle Address: Number Street City State Zip Code Home Telephone Number Cell Phone Number Office Telephone Number Social Security Number Position(s) applying for: Date Available: How did you learn about us? Date of Application: Salary Desired: Status/Hours desired: Advertisement Internet Friend School Walk-in Employee Referral Full-time Part-time If you are under 18 years of age, can you provide a work permit? Yes No Do you have any relatives currently employed by Liberty Bank? Yes No If yes, please provide name and relationship: Have you ever been employed by us before? Yes No If yes, please provide date and position: Can you provide the required proof of U.S. citizenship or work eligibility? Yes No Have you ever been convicted of a criminal offense, pled guilty, or nolo contend ere (no contest), other than for a minor traffic violation? Yes No If yes, please explain: Have you ever been discharged, resigned or been asked to resign from a job due to suspicion of theft or unauthorized possession of property or similar conduct? Yes No If yes, please explain: Rev 10/2003

2 Education Name of Institution Diploma/ Degree Major Year Graduated or Last Attended High School Business School College/University Military Special Skills, Training or Qualifications: Describe any specialized skills, training, or apprenticeships you have been involved in including military training: Do you have any of the following skills: ( Check all that apply.) Typing, wpm Personal Computer: Beginner Intermediate Advanced User Teller Terminal Word Processing Software: Word WordPerfect Works Other 10-Key Adding Machine Spreadsheet: Excel Lotus 123 Other Professional Organizations, Business, Civic or Community Activities: Describe any activities you feel may be helpful to use in considering your application for employment. You may exclude any information that reveals race, sex, religion, national origin, age, ancestry or handicap or other protected classes. Personal References: Please provide the names, addresses and telephone numbers of at least three personal references that may be contacted to provide a character reference and who are not relatives or previous supervisors: Name Relationship Phone Number If you are currently employed, may we contact your present employer? Yes No

3 Employment History: This section must be completed. (Resumes can be submitted as supplemental information.) Current or Most Recent Employer: Start Date: To: Curent/Final Pay Rate : Job Title: Telephone Number: Previous Employer: Start Date: To: Job Title: Final Pay Rate : Telephone Number: Previous Employer: Start Date: To: Job Title: Final Pay Rate : Telephone Number: Previous Employer: Start Date: To: Job Title: Final Pay Rate : Telephone Number:

4 Applicant's Statement: Please read statements below carefully before signing this employment application disclosure. I certify that the answers provided on this application are accurate and complete. I understand that any false or misleading information contained in this application or during the interview process, may result in immediate termination. I also understand that I must abide by all Bank policies and procedures. I agree to abide by all of the rules and regulations of Liberty Bank governing employees and acknowledge that continued employment is contingent upon my continuing to do so. I acknowledge the confidential nature of Liberty s business and agree to maintain the confidentiality of the business affairs of the Bank and its customers, at all times, both during and after my employment. I understand that a criminal investigation, as well as, a credit and reference check will be conducted. I also understand that during the course of my employment I may be requested to take a polygraph test if there is a reasonable suspicion that I was involved in an activity or incident which caused economic loss or injury to Liberty. I acknowledge that an offer and acceptance of employment is of an "at will" nature, which means that I may resign at any time and the employer may discharge me at any time with or without cause. I further understand that no supervisor, manager or representative of Liberty has any authority to enter into an agreement for employment for any specific period of time or to make any agreement contrary to these terms of employment, except such person or persons to whom such authority has been specifically granted by Senior Management or the Board of Directors of Liberty Bank. I agree that as a condition of employment, I expressly waive any expectation of privacy and acknowledge that the waiver related to searches of any and all personal effects brought to or maintained on Liberty s property including, but not limited to lunch boxes, purses, brief cases, clothing, and automobiles on company property. This waiver of expectation of privacy also refers to all computer and/or telecommunication systems/programs/devices used, including but not limited to , voice mail, computer storage and/or other electronic media. This could include, among other things, my desk, files, or furniture provided by Liberty. I hereby consent to such a search when and if requested by Liberty, and I understand that my failure to submit to such a search may result in my immediate termination. I voluntarily consent to submit to a drug test at the request and expense of the Bank and understand that Liberty reserves the right to conduct random drug testing and for employment purposes, may obtain consumer reports on me from time to time during my employment. I understand that my application for employment shall remain in Liberty s active files for a period of not more than 90 days. Active files will be purged of applications and/or resumes on file for more than 90 days. If I wish to extend my candidacy, I must reapply by submitting my resume or another employment application. I hereby authorize all previous employers, to release to Liberty any and all information regarding my employment. I hereby further release Liberty, and any and all of its employees, of liability relating to, or arising out of any actions based on information contained on this application. I have carefully read, understand and will comply with all aspects of the employment disclosures stated in this document, and understand that completion of this application is not to be considered an offer of employment. Signature of Applicant Date AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER FOR HUMAN RESOURCES DEPARTMENT USE ONLY Schedule Interview with Human Resources Yes No Interview Date/Time: Schedule Interview with Department: Yes No Interview Date/Time: Extend Offer: Yes No Rate of Pay: Job Title: Start Date: Date of Birth: MS: New Hire Rehire Orientation Date/Time: Report to:

5 Voluntary Affirmative Action Information (Completion of the information below is voluntary) We consider applicants for all positions without regard to race, color, religion, national origin, sex, age, disability, veterans status or any other legally protected class. We are required to comply with government regulations concurring Affirmative Action obligations where they apply. In an effort to comply with these requirements, we must provide the government with an applicant flow report. The information provided on this form will not be used as a part of your application for employment and will be maintained separate and apart from applicant files. This applicant data survey contains confidential information and will be maintained according. Your cooperation and assistance is appreciated. Position applied for: Date: Referral Source: ( Please check one.) Advertisement Government Agency Walk-in Employment Agency Relative Referral, Friend School Community Agency Applicant Information: Name: ( ) Last First Middle Area Code Phone Address: Street City State Zip Code Sex: Male Female Equal Employment Opportunity Identification Groups: ( Please check one.) White Black (not of Hispanic origin) Hispanic American Indian/Alaskan Native Asian/Pacific Islander Vietnam Era Veterans, Disabled Veterans and Individuals with Physical/Mental Disabilities: ( Please check one.) Vietnam Era Veteran (served between 1964 and 1975) Disabled Veteran Individual with a disability

6 Drug Test Consent and Release Form I,, hereby voluntarily consent to submit to a drug test at the request and expense of Liberty Bank. It is understood that I am submitting to this test of my own free will. I give permission to the testing laboratory to release my test results to Liberty Bank. I further understand that refusal to submit to this test will be considered voluntary withdrawal of my employment application. I am taking or have taken the following medication within the past days: Name of Medication Condition for which taken Prescribing Physician I hereby authorize all treating physicians to verify the prescriptions listed above by date, usage and condition prescribed. I understand that the results of my drug test will be held in strict confidence and that only Liberty Bank management with hiring responsibility and Human Resources will have access to the results. Applicant's Signature Date

7 Credit Check Consent and Release Form I,, hereby voluntarily consent to Liberty Bank and Trust Company conducting a credit check as a part of their employment process and understand that for employment purposes, may obtain consumer reports on me from time to time during my employment. I understand that I will receive a copy of the credit bureau report for my information. When the information contained in my report may affect my employment status, I will be given an opportunity to respond in writing within five business days to any derogatory or inaccurate information contained in my report. My correspondence must be directed to the Vice President, Human Resources. It is also my responsibility to contact the appropriate credit reporting agencies to correct any discrepancies. I hereby authorize Liberty to conduct an investigation of my credit history. I understand that the results of that investigation will be held in strict confidence and that only Liberty Bank Management with hiring responsibility and the Human Resources Department will have access to the results. Applicant s Signature Date -- Human Resources Only Date Credit Report given to applicant: Date offer suspended: Date response received:

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