Employment Application

First Name Last Name Middle Initial Date

Street Address Apartment/Suite #

Phone Number Alternate Phone Number

Email Address Date Available

Position Applying For

Type of Position Full-time Part-time

Are you a Citizen of the United States? Yes No

If No, are you authorized to work in the US? Yes No

Have you ever worked for this company? Yes No

If Yes, when?

Have you ever been convicted of a felony? Yes No

If Yes, explain?

How did you learn of this position? Western State Bank Website Newspaper Word of Mouth Job Service

Other

Company Phone Number

Address (City/State) Supervisor Name & Title

Job Title Starting Salary $ Ending Salary $

Starting Position Ending Position

From To Reason for Leaving

May we contact your present employer? Yes No

May we contact you at your present employer? Yes No

Company Phone Number

Address (City/State) Supervisor Name & Title

Job Title Starting Salary $ Ending Salary $

Starting Position Ending Position

From To Reason for Leaving

Company Phone Number

Address (City/State) Supervisor Name & Title

Job Title Starting Salary $ Ending Salary $

Starting Position Ending Position

From To Reason for Leaving

High School City State

Did you graduate? Yes No

Major Course of Study & Degree earned

Did you graduate? Yes No

Major Course of Study & Degree earned

Certificate Name Organization Completion Date

Are you a veteran? Yes No

Company / Occupation Phone

Address City State Zip

Company / Occupation Phone

Address City State Zip

Company / Occupation Phone

Address City State Zip

We are an equal opportunity employer and will provide reasonable accommodation to qualified employees and applicants with disabilities in conformity with state and federal law. Western State Agency provides a smoke and tobacco-free environment for its customers and employees. No smoking is allowed by Western in buildings, company vehicles or within 20 feet of any entrance, operable window or air exchange unit.

I certify that all information I have provided to Western is true, correct and complete. False, incomplete or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

I authorize, without reservation, Western, its representatives, employees or agents to contact and obtain information from previous employers, educational institutions and references I provided through this application, resume or job interview. I waive all rights and claims I may otherwise have against Western or its representatives, for seeking and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

I understand that Western does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

Western's application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that, if hired, I am free to resign at any time, with or without cause and with or without notice, and Western reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I certify that I have read, fully understand and accept all terms of the above statement:

Signature of Applicant Date

By typing your name above, you certify your identify & the accuracy of the information presented herein.

It is the policy of this organization to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, sex, age, veteran status or disability. As an affirmative action employer under E.O.11246, we invite all applicants to identify themselves as indicated below.

COMPLETION OF THIS FORM IN NO WAY AFFECTS THE DECISION REGARDING YOUR APPLICATION FOR EMPLOYMENT. THIS FORM IS CONFIDENTIAL AND WILL BE MAINTAINED SEPARATELY FROM YOUR APPLICATION FORMEMPLOYMENT APPLICATION.

Position applied for (list only one) Where did you hear about this job?

I elect not to identify
(Check and be sure to sign below even if you elect not to identify.)

Race/Ethnic Identification

Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

If you did not check "Hispanic or Latino" above, please select one of the following race/ethnic identifications.

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, Guam, 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 Phillipine 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.

Signature of Applicant Date

By typing your name above, you certify your identify & the accuracy of the information presented herein.

Applicant Information

Previous Employment

Education

Occupational License / Certificates

Military Background Information

References

General Information

Applicant Statement

Applicant Affirmative Action Information

Gender Identification

Race/Ethnic Identification