Social Security Number: If under 18 years of age, do you have a work permit? Yes No

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1 APPLICATION FOR EMPLOYMENT Bridgeway Federal Credit Union Federal and state laws prohibit discrimination in employment based on race, religion, gender, national origin, age disability, marital status, veteran status, military obligations or association with any of the above. Bridgeway Federal Credit Union is committed to the principles of equal employment and intends to comply with all applicable laws. Personal Information Date: Name: First Middle Initial Last Present Address: Street City State/Zip Telephone:( ) Social Security Number: If under 18 years of age, do you have a work permit? Yes No Are you either a US citizen or an alien with legal right to work in the US? Yes No (You will be required to furnish proof of lawful work status if you are offered a job). Are you fully able to perform the duties of the job(s) for which you have applied, Yes No with or without reasonable accommodation? If no, please describe any task, which you are not able to perform with or without reasonable accommodation: Have you ever been convicted of a crime? If yes, please describe fully the Yes No conviction(s), the nature of the offense, your age at the time of the offense and any rehabilitation since the conviction. A conviction record will not necessarily be a hinder to employment. Type of employment desired; Full Time Part Time Temporary Desired Shift Position(s) applied for: Date you can begin: Have you ever worked for the credit union before? Yes No Reason for leaving: Do you speak any languages other than English? Yes No Languages:

2 Education Highest Grade Completed: Grade School High School College Name of last school attended: License, Vocational or Trade Training: Employment History List below your work experience (starting with your present or most recent employer) for the last five years or your last four employers, whichever will provide us with the most and best information about you. Use the reverse side of the application form if you need additional space. Please account for all periods of unemployment in this section. Dates of Employment: Name, Address & Phone Number of Employer: Salary: Briefly describe your job duties and work experience: Reason for leaving: Dates of Employment: Name, Address & Phone Number of Employer: Salary: Briefly describe your job duties and work experience: _ Reason for leaving: Dates of Employment: Name, Address & Phone Number of Employer: Salary: Briefly describe your job duties and work experience: Reason for leaving:

3 Dates of Employment: Name, Address & Phone Number of Employer: Salary: Briefly describe your job duties and work experience: Reason for leaving: Employment References List the names and telephone numbers of at least three work-related references (not related to you). Name: Telephone ( ) Years known: Name: Telephone ( ) Years known: Name: Telephone ( ) Years known: Applicant s Statement I understand that if am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the credit union s service, whenever it is discovered. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I give the credit union the right to contact and obtain information from all credit references, personal references, employers, educational institutions and to otherwise verify the accuracy of the information contained in the application. I hereby release from liability the credit union and its representative for seeking, gathering and using information and all other persons, corporations or organizations for furnishing such information. The credit union does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from the credit union and still wish to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the credit union reserves the same right to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the credit union, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand it is the company s policy not to refuse to hire a qualified individual with a disability because of that person s need for a reasonable accommodation as required by the ADA. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions. Applicant s Signature Date

4 EMPLOYMENT APPLICANT DISCLOSURE AND RELEASE I understand that a Consumer Report and/or Investigative Consumer Report will be conducted on me for employment purposes. By signing the release below, I hereby authorize Bridgeway Federal Credit Union to contact any and all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to, information about employment, education, consumer credit history, driving record, criminal record and general public records history. I release from all liability all persons, companies, schools supplying such information. I hereby indemnify Bridgeway Federal Credit Union against any liability, which may result from making such requests. This release shall remain in effect for the length of my employment. I understand and I may have a right to request additional disclosures regarding the nature and scope of the investigation. I also understand that I may request (in writing) a copy of the consumer report and a written description of my rights under the Fair Credit Reporting Act. I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I fully understand the terms of this release. Name: (Please print) Other names used: Address: City/State/Zip: Date received degree (if applicable) Social Security #: Driver's License Number & State: (Signature of Applicant) (Date)

5 Voluntary Self-Identification of Disability Why are you being asked to complete this form? Form CC-305 OMB Control Number Expires 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

6 Voluntary Self-Identification of Disability Reasonable Accommodation Notice Form CC-305 OMB Control Number Expires 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.

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