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Skagit Bank Employment Application

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IDENTIFICATION

First

Middle

Last

Address

City

State

Zip

Length of time at this address

Home Phone #

Cell Phone #

E-mail Address

POSITION APPLIED FOR

Position Applied For

Salary Desired

Full TimePart TimeSummer
Indicate below the times you are available to work:
  • Mon.
  • Tues.
  • Wed.
  • Thur.
  • Fri.
  • Sat.

How were you referred to us?

Date available for work

GENERAL INFORMATION

Are you a Former Employee?

Under What Name (If Different)

Former Position/Title

Dates of Former Employment

Location

Are you legally eligible for employment in this country?
YesNo
Documentation providing legal right to work in the United States will be required upon hiring.

Have you ever been refused for fidelity bond coverage?
YesNo

Have you ever admitted or been convicted of a criminal offense (including felonies, misdemeanors, petty misdemeanors and pre-trial diversion programs) other than a minor traffic offense?
YesNo
If yes, please provide date(s) and details below.
As a federally insured financial institution, Skagit Bank is prohibited by Title 12 of the United States Code, Section 1829, from employing or continuing to employ any individual who has been convicted, or who is hereafter convicted, of any criminal offense involving dishonesty, breach of trust, or money laundering without the written consent of the Federal Deposit Insurance Corporation (FDIC). While criminal convictions will not necessarily bar employment, Skagit Bank reserves the right to deny or terminate employment for convictions involving dishonesty, breach of trust, or other criminal offenses at its sole discretion.

EDUCATION RECORD

High School Name

Address

Major Course or Subject

Degree Earned

GPA

List scholastic honors, offices held and activities in high school and college:

Are you planning to pursue further studies?
YesNo
Day SchoolNight School

If yes, please describe:

List any courses you have taken or additional experience you may have that would be applicable or beneficial to the position for which you are applying:

EMPLOYMENT RECORD

Starting with the Present or Most Recent, list previous employment.
Employer

Address

City & State

Zip

Phone

Employed From

Employed To

Starting Salary

Ending Salary

Type of Business

Immediate Supervisor & Title

Full-timePart-timeTemporary

Job Title & Duties

Reason for Leaving

May we contact for reference?
YesNo

Eligible for Rehire?
YesNo

If presently employed, why do you desire to change your position?

List Periods of Unemployment of more than 30 days and explain.

REFERENCES

List three business or personal references you have known for the past Five years. Do NOT give relatives.

Reference 1
Name

Address

Phone

No. Years Acquainted

Occupation

Reference 2
Name

Address

Phone

No. Years Acquainted

Occupation

Reference 3
Name

Address

Phone

No. Years Acquainted

Occupation

AFFIRMATIVE ACTION APPLICATION DISCLOSURE

Skagit Bank is committed to providing equal employment opportunities, and in accordance with federal law, maintains an Affirmative Action Program. In order to accurately track the ethnic background and gender of individuals who are interested in working for us, we request that you complete this form. Completion of this form is strictly voluntary. This information will be kept confidential and separate from your employment application, will not be used for evaluating your application for employment, and will in no manner affect your employment relationship with us.

Name

Date

Location

Position Applying For

How Did You Hear of this Position?

Gender
(Please check one)
Male
Female
Decline to Answer

Racial/Ethnic Background
(Please check one)
Hispanic or Latino
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.)
Black or African American ~ not Hispanic or Latino
(A person having origins in any of the black racial groups of Africa.)
White ~ not Hispanic or Latino
(A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
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 Philippine Islands, Thailand, and Vietnam.)
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.)
American Indian or Alaskan 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.)
Decline to Answer

Federal Veteran Status
(Please check one if it describes your veteran status)
Vietnam Era Veteran
A Vietnam Era veteran is a person who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released with other than a dishonorable discharge; (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964, and May 7, 1975; or (3) served on active duty for more than 180 days and served in the Republic of Vietnam between February 28, 1961, and May 7, 1975.
Special Disabled Veteran
A veteran 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 Department of Veteran Affairs for a disability rated at 10 or 20 percent in the case of a veteran who has been determined to have a serious employment disability; or (B) a person who was discharged or released from active duty because of a service-connected disability.
Disabled Veteran
A veteran of the US 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 the 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.
Armed Forces Service Medal Veteran
Any veteran who, while serving on active duty in the US military, ground, naval, or air service, participated in a US military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985
Other Protected Veteran
A veteran who served on active duty in the US military, ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under laws administered by the Department of Defense.
Decline to Answer

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017

Why Are You Being Asked To Complete This Form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.1 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
    Deafness
    Cancer
    Diabetes
    Epilepsy
  • Autism
    Cerebral Palsy
    HIV/AIDS
    Schizophrenia
    Muscular Dystrophy
  • Bipolar Disorder
    Major Depression
    Multiple Sclerosis (MS)
    Missing Limbs or Partially Missing Limbs
  • Post-Traumatic Stress Disorder (PTSD)
    Obsessive Compulsive Disorder
    Impairments requiring the use of a wheelchair
    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

Date

Reasonable Accommodation Notice
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.

1. 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 www.dol.gov/ofccp.

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.

APPLICANT STATEMENT

I certify that the information given by me to Skagit Bank is true and complete to the best of my knowledge. I understand that any false or misleading statement or omission of material fact may result in the disqualification of my application or my dismissal if already hired. I authorize Skagit Bank to solicit information regarding my character, general reputation, credit, previous employment and similar background information, and to contact any and all references I have given on my application. I hereby release all parties and persons connected with any such request for information from all claims, liabilities and damages for any reason arising out of the furnishing of such information, whether such information is favorable or unfavorable. If employed, I release Skagit Bank from any liability for future references it may provide regarding my work history at Skagit Bank. If I am hired, I understand that my employment can be terminated with or without cause, and with or without notice at any time, at the option of either Skagit Bank or myself. I understand that I am an at-will employee. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of Skagit Bank has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, except those in writing signed by the CEO of Skagit Bank. If employed, I further agree that if Skagit Bank advances any paid leave before it has been accrued, or advances or loans me any money during the course of my employment, or if I lose, damage, or fail to return any Skagit Bank property, Skagit Bank is authorized to deduct from my wages sufficient funds to repay such loans or advances or to replace its property. In the event of my employment with Skagit Bank, I will comply with all rules and regulations as set forth in the Bank’s Employee Handbook and other communications distributed to me.

DO NOT SUBMIT FORM UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I have read, fully understand, and accept all terms of the above Applicant Statement.*

Please Note: In order to complete the Disclosure & Authorization of Consumer Report and Release & Authorization for Background Investigation sections of this form we will need your Social Security Number. At the appropriate time during our recruiting process, you will be contacted to complete the form.

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Skagit Bank is an Equal Opportunity/Affirmative Action Employer and does not unlawfully discriminate on the basis of race, sex, age, color, religion, national origin, marital status, Veteran status, disabled status, or any other basis prohibited by Federal, State or Local law.

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