FSM APPLICATION

APPLICANT INFORMATION
Last Name
First
Middle Name
Date

MonthDayYear
Date
Street Address
Apartment/Unit
City
State
ZIP
Phone
E-mail Address
example@example.com
Date of Birth

MonthDayYear
Date
Please check if you do NOT want your current employer contacted.

Do NOT contact current employer
Date Available

MonthDayYear
Date
Social Security No.
Desired Salary
Position Applied for
NMLS
Are you a citizen of the United States?

YESNOIf no, are you authorized to work in the U.S.?YESNO
Have you ever worked for this company?

YESNO
If so, when?
Have you ever been convicted of a felony?

Have you ever been convicted of a felony? YESNO
If yes, explain
EDUCATION
High School
Address
From
To
To

Did you graduate? YESNO
Degree
College
Address
From
To
To

Did you graduate? YESNO
Degree
Other
Address
From
To
To

Did you graduate? YESNO
Degree
REFERENCES
Please list three professional references.
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
PRESENT EMPLOYER
Company
Phone
Address
Supervisor
Job Title
Responsibilities
Start Date

MonthDayYear
Date
May we contact your present employer?

NOYES
PREVIOUS EMPLOYMENT
Company
Phone
Address
Supervisor
Job Title
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?

YESNO
Company
Phone
Address
Supervisor
Job Title
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?

YESNO
Company
Phone
Address
Supervisor
Job Title
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?

YESNO
MILITARY SERVICE
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature

Clear
Date

MonthDayYear
APPLICATION FOR EMPLOYMENT
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 180 days. If I wish to be considered for employment beyond this time period, I understand that I need to inquire as to whether or not applications are being accepted at that time.

I understand that neither this document nor any offer of employment from the employer constitutes an employment contract unless a specific document to that effect is executed by the employer and me in writing.

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

Clear
Date

MonthDayYear
Thank you for applying at First State Mortgage Services, LLC. Your resume is being carefully considered. We will contact you if your qualifications meet our needs. Attached is an Equal Employment Opportunity Survey. In order to meet our affirmative action objectives and to comply with the Federal and/or State law requirements, you are invited to provide the information requested below. Providing this information is voluntary. Your application for employment will not be adversely affected based upon your decision to respond or decline to respond. Please return the EEO Survey via email, fax or by mail to the address below.

Hispanic or LatinoNot Hispanic or LatinBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteSex: MaleSex: FemaleCitizenship: United States Permanent ResidentCitizenship: Temporary VisaVietnam Era Veteran* Yes
NOTE: Suporting documentation (DD214/DD215 and, for Disabled Veterans, a copy of your veterans’ disability preference letter from the Department of Veterans’ Affairs unless that information is included in the DD214/215 form) MUST be submitted to establish eligibility.

Disabled Veteran* Yes
If you are a qualified individual with a disability* and you need reasonable accommodation to participate in the hiring process or in employment if hired for this position, please contact Lydia Walk. Tel: (309) 664-7038; Fax (309) 664-7038; Email: lwalk@fsmloans.biz.

Person with a Disability (ADA Regulations)*: Yes
How did you hear about this position:
Name:
Last:
Middle:
Position applied for:
Department:
FOR HUMAN RESOURCES USE ONLY:

Disposition: Not Interviewed: Interviewed by not hired: Interviewed and hired

EEO Code: (1.1) Executive/Senior Level Officials and Managers; (1.2) First/Mid-Level Officials and Managers; (2) Professionals; (3) Technicians; (4) Sales Workers; (5) Administrative Support Workers; (6t) Craft Workers; (7) Operatives; (8) Laborers and Helpers; (9) Service Workers

*Group definitions can be found below.
Self-Identification Descriptions
Hispanic or Latino -A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

White, not of Hispanic Origin -A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American, not of Hispanic Origin -A person having origins in any of the black racial groups of Africa.
Asian, not of Hispanic Origin -A person having origins in any of the original peoples of the Far East, Southeast Asia, including, for example, Cambodia, China, Japan, Korea, Malaysia, the Philippine Islands, Thailand, and Vietnam.
NHOPI. Native Hawaiian or Other Pacific Islander, not of Hispanic Origin -A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

American Indian or Alaskan Native, not of Hispanic Origin -A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Qualified Individual with a Disability is an individual with a disability as defined under the Americans with Disabilities Act who satisfies the requisite skill, experience, education and other job-related requirements of the employment position held or desired and is able to perform the essential functions of that position, either with or without reasonable accommodation.

Disabled Veteran is a person entitled to disability compensation under laws administered by the United States Department of Veterans Affairs for disability rated 30 percent or more, a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

Please return this form via one of the following methods:

Via Mail: First State Mortgage Services,LLC Attn: Lydia Walk 502 North Hershey Road, Bloomington, IL 61704 Via fax: (309) 807-0238 Email: lwalk@fsmloans.biz
Consumer Authorization
Authorization: By signing below, you authorize: (a) General Information Services, Inc. (“GIS”) to request information about you from any public or private information source; (b) anyone to provide information about you to GIS; (c) GIS to provide us one or more reports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your employment. GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make this authorization to be valid for as long as you are an applicant or employee with us.

The Consumer Financial Protection Bureau’s “Summary of Your Rights under the Fair Credit Reporting Act” is attached to this authorization. If you are a New York applicant, a copy of New York’s law on the use of criminal records is attached. By signing below, you acknowledge receipt of these documents.
Personal Information: Please print the information requested below to identify yourself for GIS.
Name

First NameMiddle NameLast Name
Middle name

No
Other names
Current and former addresses:
from Mo/Yr
Street
City, State & Zip
from Mo/Yr
to Mo/Yr
Street
City, State & Zip
From Mo/Yr
to Mo/Yr
Street
City, State & Zip
Some government agencies and other information sources require the following information when checking for records. GIS will not use it for any other purposes.
Date of birth

MonthDayYear
Date
Social security number
Driver's license number & State
Name as it appears on license
Report Copy: If you are applying for a job or live in California, Minnesota, or Oklahoma, you may

request a copy of the report by checking this box:
request a copy of the report by checking this box:
Signature

Clear
Date

MonthDayYear
Date
Consumer Disclosure
We (First State Mortgage) will obtain one or more consumer reports or investigative consumer reports (or both) about you for employment purposes. These purposes may include hiring, contract, assignment, promotion, re-assignment, and termination. The reports will include information about your character, general reputation, personal characteristics, and mode of living.

We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is General Information Services, Inc. GIS’s address is P.O. Box 353, Chapin, SC 29036. GIS’s telephone number is (866) 265-4917. GIS’s website is at www.geninfo.com, where you can find information about GIS’s international privacy practices.

To prepare the reports, GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources.

You may obtain a copy of any report that GIS provides and GIS’s files about you (in person, by mail, or by phone) by providing identification to GIS. If you do, GIS will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification.

If GIS obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed.
Please sign below to acknowledge your receipt of this disclosure.
Signature

Clear
Date

MonthDayYear
Printed Name
Sample Consumer Disclosure | Last modification date: 2/7/2013
Should be Empty:

APPLICANT INFORMATION

EDUCATION

REFERENCES

PRESENT EMPLOYER

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE

APPLICATION FOR EMPLOYMENT

Applicant’s Statement

Self-Identification Descriptions

Consumer Authorization

Consumer Disclosure