(Please Print) How did you learn about us? Advertisement Friend Relative Walk-in Employment Agency. Last Name First Name Middle Initial

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1 APPLICATION FOR EMPLOYMENT We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law. Position(s) applied for (Please Print) Date of Application How did you learn about us? Advertisement Friend Relative Walk-in Employment Agency Other: Last Name First Name Middle Initial Address City, State Zip Code Telephone Number (s) Social Security Number If under 18 years of age, can you provide proof of 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(s): 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. On what date would you be available for work? Are you available to work: Full-time Part-time Shift work Temporary Are you currently on "lay-off" status and subject to recall? Yes No Can you travel if a job requires it? Yes No Have you ever been convicted of a felony? Yes No Conviction will not necessarily disqualify an applicant from employment. If yes, please explain: WE ARE AN EQUAL OPPORTUNITY EMPLOYER

2 EDUCATION Elementary Name & Address Of School Course of Study Years Completed Diploma/Degree High School Undergraduate Graduate/ Professional Other (specify) Indicate any foreign languages you can speak, read and/or write: Fluent Good Fair SPEAK READ WRITE Describe any specialized training, apprenticeship, skills, and extra-curricular activities. _ Describe any job-related training received in the United States military. _

3 EMPLOYMENT EXPERIENCE Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other protected status. (If you need additional space, please continue on a separate sheet of paper). Employer Dates Employed: Job Title/Work Performed: Address From To Telephone Number(s) Hourly Rate/Salary: Supervisor Starting Final Reason for leaving Employer Dates Employed: Job Title/Work Performed: Address From To Telephone Number(s) Hourly Rate/Salary: Supervisor Starting Final Reason for leaving Employer Dates Employed: Job Title/Work Performed: Address From To Telephone Number(s) Hourly Rate/Salary: Supervisor Starting Final Reason for leaving Employer Dates Employed: Job Title/Work Performed: Address From To Telephone Number(s) Hourly Rate/Salary: Supervisor Starting Final Reason for leaving

4 List Professional, Trade, business or civic activities and offices held. You may exclude memberships that 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) Fax Windows Production/Mobile Other (list): Microsoft Excel Machinery (list): Calculator Microsoft Word Typewriter 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 description of the activities involved in such a job or occupation is attached. Yes No

5 REFERENCES 1. Name: Phone # ( ) Address: 2. Name: Phone # ( ) Address: 3. Name Phone #( ) Address: Applicant's Statement I certify that answers given herein are true and complete to the best of my knowledge. 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 the 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. _ Signature of Applicant Date

6 FOR PERSONNEL DEPARTMENT USE ONLY Arrange Interview Yes No Remarks: Interviewer Date Employed Yes No Date of employment: Job Title: Department: Hourly Rate/Salary: By: Name and Title Date NOTES

7 Voluntary Self-Identification Form for Applicants First Bank is an Equal Opportunity Employer. We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights and regulations. In order to comply with these laws, we invite our employment applicants to voluntarily self-identify certain specified categories. Submission of this information is completely voluntary and refusal to provide it will not subject you to any adverse treatment. Whether or not you respond will not affect our consideration of your application. This information will be kept confidential in accordance with state and federal laws, and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations. We may be required to summarize such data for government reporting purposes, and if so, such data will not identify any specific individual. Name: Position Applied For: Date of Application: Ethnicity Category: Please check one Ethnic Category Equal Employment Ethnicity Definition Hispanic/Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. American Indian or Alaska Native A person having origins in any of the original peoples of North and South American (including Central America); and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African A person having origins in any of the black racial groups of Africa. American Native Hawaiian or Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Two or more races Any combination of the categories above.

8 Gender Category: Female Male Veteran Status: Vietnam Era Veteran Special Disabled Veteran Other Protected Veteran Recently Separated Veteran I am not a veteran I do not wish to self-identify Signature: Date: May 2014

9 Voluntary Self-Identification of Disability Why are you being asked to complete this form? Form CC-305 OMB Control Number Expires 1/31/2017 Page 9 of 10 Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. i 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 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 Autism Bipolar disorder Post-traumatic stress disorder (PTSD) Deafness Cerebral palsy Major depression Obsessive compulsive disorder Cancer HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair Diabetes Epilepsy Schizophrenia Muscular dystrophy Missing limbs or partially missing limbs 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 Your Name Today s Date

10 Voluntary Self-Identification of Disability Reasonable Accommodation Notice Form CC-305 OMB Control Number Expires 1/31/2017 Page 2 of 10 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. i 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 PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons 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.