Job Application Form w Specific Listings

EMPLOYMENT HISTORY
List Last Three Employers, Starting with the Most Recent One First
Do you have prior employment history?*

YesNo
If employment history is listed on resume, please click yes to skip ahead to page 8. If no is selected, please continue with application.

YesNo

Name of Present or Last Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Starting Date

MonthDayYear
Date
Leaving Date

MonthDayYear
Date
Job Title
Starting Salary
Final Salary
May We Contact Your Supervisor

YesNo
Name of Supervisor
Title
Phone Number

Area CodePhone Number
Description of Work
Reason for Leaving
Name of Previous Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Starting Date

MonthDayYear
Date
Leaving Date

MonthDayYear
Date
Job Title
Starting Salary
Final Salary
May We Contact Your Supervisor

YesNo
Name of Supervisor
Title
Phone Number

Area CodePhone Number
Description of Work
Reason for Leaving
Name of Previous Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Starting Date

MonthDayYear
Date
Leaving Date

MonthDayYear
Date
Job Title
Starting Salary
Final Salary
May We Contact Your Supervisor

YesNo
Name of Supervior
Title
Phone Number

Area CodePhone Number
Description of Work
Reason for Leaving

GENERAL
Describe any job related specialized training, apprenticeship, skills and extra-curricular activities: (Please do not include any information that would reveal a protected class status)
List any job-related professional or technical organizations to which you belong: (Please do not include any information that would reveal a protected class status)

SPECIALIZED SKILLS
You May Select Multiple Skills*

WordOutlookExcelDesktop PublishingPowerPoint10-KeyOther

EDUCATION
High School

School Name

Location

Course of StudyYears Completed

Diploma or Degree
College

School Name

Location

Course of StudyYears Completed

Diploma or Degree
Trade, Business or Correspondence School

School Name

Location

Course of StudyYears Completed

Diploma or Degree

PROFESSIONAL REFERENCES
Reference I.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business
Phone Number

Area CodePhone Number
Years Acquainted
Reference II.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business
Phone Number

Area CodePhone Number
Years Acquainted
Reference III.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business
Phone Number

Area CodePhone Number
Years Acquainted

APPLICANT'S STATEMENT
Can you meet the job requirements of the position for which you applied with or without an accommodation?*

YesOther
Can you meet the work schedule or attendance requirements of the job?*

YesOther
Can you, if employed, submit verification of your legal right to work in the United States?*

YesOther
I certify that the facts contained in this application and any accompanying resume are true and complete to the best of my knowledge. I understand that any falsification, omission, misrepresentation or concealment of information on this application or resume may be sufficient grounds for disqualification from further consideration for hire or immediate discharge and that the company shall not be liable in any respect if my employment is so denied or terminated.

I authorize investigation and verification of all statements contained herein and the references and former employers and employees to give you any and all information concerning my previous employement and any pertinent information they may have, personal or otherwise to include credit history, education, employment verification, personal references and criminal records. I release the company from all liability for any damage that may result from receiving and/or using such information.

I hereby understand and acknowledge that 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 Employee at any time with our without cause or notice. 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 organiztion. I also understand that this application and any employee manuals or handbooks that may be distributed to me shall not be construed or relied upon as a contract.
Signature of Applicant*
Date*

MonthDayYear
Date

At this time, we are asking you to help us meet our obligations by completing the forms and information listed on the following pages. Please note that the information will only be used in accordance to the provisions of applicable laws, executive orders, and regulations. Providing this information is voluntary and refusal to so will not result in any adverse treatment. The information you provide will be held in strict confdence except that:
- Necessary management and supervisory personnel may be informed to ensure proper placement and to provide reasonable job accommodations;
- First aid and safety personnel may be informed to the extent appropriate, if the condition might require emergency treatment; and
- Government officials investigating affirmative action program compliance may have access to reported information.
Thank you for your cooperation in this important initiative.

Molly David
HR Manager
First National Bank Minnesota

You may submit your application now if you wish to not provide the voluntary information requested.

VOLUNTARY SELF-IDENTIFCATION OF DISABILITY
Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005
Expires 1/31/2020

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. 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 on of the options:

Yes, I have a disability (or previously had a disability)No, I don't have a disabilityI don't wish to answer
Your Name
Date

MonthDayYear
Date
OMB Control Number 1250-0005

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.

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2020 Page 2 of 2

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. i

[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.