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Application for Position:

INSTRUCTIONS: Please complete all portions of this employment application to be considered for employment. If you require accommodation during the employment process, including assistance in the completion of this employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a three-month period after submission to the credit union and only for the desired position. Consideration for employment after the three-month period requires completion and submission of a new application.

* Indicates a required field.

PERSONAL INFORMATION

*Last Name:
*First Name:
*Social Security Number: - -
(for bondability and criminal conviction checks)
*Present Physical Address:
Present Mailing Address (if different than above):
Contact Information:
*Phone:
() - ext
Work Phone:
() - ext
Alternate Phone:
() - ext
*Email Address:
Alternate Email:
Driver’s License Number (if driving is an essential job function):
State:
*Have you ever used any other names?   
(for background and criminal conviction checks)
If yes, please explain:
*Can you, upon employment, submit verification of your legal right to work in the United States and proof of age?   
(If offered, employment you will be required to submit documentation required by the IRCA.)
*Have you ever been convicted of a crime or entered a pretrial diversion program to avoid a conviction?   
If yes, please list:
*Are there any felony charges pending against you?   
If yes, please provide date(s) and details:
Answering "yes" to these last three questions does not constitute an automatic bar to employment. Factors, such as date of offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account.

DESIRED EMPLOYMENT

*Position applying for:

*Date you can start:

*Pay expected:

*Desired Time:
*Have you applied for work with us before?   
Where?
When?
*Have you worked for us before?   
Where?
When?
*Apart from religious services, will you be able to work all other times?   
(If hired, you will be required to perform work as required by the credit union.)
*Who referred you to us?

EDUCATIONAL BACKGROUND

*High School:
*Major:
*Years There:
*Graduated?
  
  
Technical School:
Major:
Years Spent:
Graduated?
  
Degree/Diploma:
College:
Major:
Years Spent:
Graduated?
  
Degree/Diploma:
College:
Major:
Years Spent:
Graduated?
  
Degree/Diploma:
Graduate School:
Major:
Years Spent:
Graduated?
  
Degree/Diploma:
Other:
Major:
Years Spent:
Graduated?
  
Degree/Diploma:

EMPLOYMENT

Starting with your present or last job, provide complete employment history for the last 10 years. You must answer all questions and this employment history must be completed even if you submit a resume.
1. *Name of Employer:
*Phone Number:
() - ext
*Street
*City
*State
*Zip code
*Beginning Date of Employment:
*Ending Date of Employment:
*Beginning Wage/Salary:
*Ending Wage/Salary:
*Position Title and Duties:
*Reason for leaving:
*Supervisor’s Name:
*May we contact this employer?   
If no, explain:
2. Name of Employer:
Phone Number:
() - ext
Beginning Date of Employment:
Ending Date of Employment:
Beginning Wage/Salary:
Ending Wage/Salary:
Position Title and Duties:
Reason for leaving:
Supervisor’s Name:
May we contact this employer?   
If no, explain:
3. Name of Employer:
Phone Number:
() - ext
Beginning Date of Employment:
Ending Date of Employment:
Beginning Wage/Salary:
Ending Wage/Salary:
Position Title and Duties:
Reason for leaving:
Supervisor’s Name:
May we contact this employer?   
If no, explain:

REFERENCES

Please provide the names of three persons you are not related to, you have known at least one year and whom we may contact.
*Name:
*Address:
*Phone:
() - ext
*Yrs. known:
*Name:
*Address:
*Phone:
() - ext
*Yrs. known:
*Name:
*Address:
*Phone:
() - ext
*Yrs. known:

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS

*Summarize your job skills, training and/or study that are relevant for the desired position. Also, explain any periods that you were not working.

DISCLOSURES FOR EMPLOYMENT APPLICATION

Fair Credit Reporting Act Disclosure and Authorization

Disclosure: Extra Credit Union, when considering your application for employment, when making a decision whether to offer you employment, when deciding whether to continue your employment if you are hired, and when making other employment related decisions directly affecting you, may wish to obtain and use a credit bureau report. These terms and conditions are defined in the Fair Credit Reporting Act (FCRA), which applies to you. As an applicant for employment or employee of Extra Credit Union, you are a consumer with rights under the FCRA. A summary of your rights under the FCRA is attached to this Application for Employment. If Extra Credit Union obtains a credit bureau report about you, and if the information contained in the said report is the reason not to hire you, you can request a free copy of the report. In addition, Extra Credit Union will advise you if you were negatively affected by credit bureau report information of its impact on the decision not to extend an offer of employment. You may also contact the Federal Trade Commission about your rights under the FCRA as a consumer with regard to credit bureau reports. Authorization: I understand that a check in the "yes" box, along with my signature at the bottom of this Application for Employment, is authorization for Extra Credit Union to request a personal credit bureau report on me and to use the information to assist in the determination of my eligibility for employment. If hired, this Disclosure and Authorization will remain on file and will serve as my ongoing authorization for Extra Credit Union to obtain personal credit bureau reports for employment purposes. I understand that I have rights under the Fair Credit Reporting Act.

Application Statement

I certify that all information that I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions to otherwise verify the accuracy of all information provided by me in this application, on my resume or during a job interview. I hereby waive any and all rights and claims I may have regarding this employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. If I am hired, I understand that my employment with Extra Credit Union is at-will. I understand that "at-will" means that either Extra Credit Union or I may terminate my employment at Extra Credit Union at any time with or without notice and with or without cause. I further understand that the at-will nature of my employment cannot be altered by any oral or written statement or practice of Extra Credit Union and that any alteration of the at-will nature of my employment must be in writing and signed by the President/CEO of Extra Credit Union. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I also understand that if I am hired, I agree to submit a medical examination and drug test, if required, before starting work. If employed, I also agree to submit a medical examination or drug test at any time deemed appropriate by Extra Credit Union and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to Extra Credit Union the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, may be contingent upon satisfactory medical examinations and drug tests, and if I am hired a condition of my employment will be that I abide by Extra Credit Union’s Drug and Alcohol Policy as found in the Employee Handbook. I understand that filling out this form does not indicate that there is a position open and does not obligate Extra Credit Union to hire me. If hired, I agree to abide by all company work rules, policies and procedures. Extra Credit Union retains the right to revise its policies or procedures, in whole or in part, at any time. I also understand that if I assert a claim against Extra Credit Union arising out of my application for employment, my employment, or my discharge from employment, I must do so within 180 days of the event giving rise to the claim or within the applicable limitations period, whichever is sooner. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE FAIR CREDIT REPORTING ACT DISCLOSURE AND AUTHORIZATION AND APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Fair Credit Reporting Act Disclosure and Authorization and Applicant Statement.

Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment —or to take another adverse action against you —must tell you, and must give you the name, address, and phone number of the agency that provided the information.
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
  • a person has taken adverse action against you because of information in your credit report;
  • you are the victim of identify theft and place a fraud alert in your file;
  • your file contains inaccurate information as a result of fraud;
  • you are on public assistance;
  • you are unemployed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need —usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.
  • You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "pre-screened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
  • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit. States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law.
For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are: TYPE OF BUSINESS/CONTACT: -CRAs, creditors and others not listed below Federal Trade Commission Bureau of Consumer Protection - FCRA Washington, DC 20580 · 202-326-3761 -National banks, federal branches/agencies or foreign banks (word "National" or initials "N.A." appear in or after bank’s name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 · 800-613-6743 -Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551· 202-452-3693 -Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution’s name) Office of Thrift Supervision Consumer Programs Washington, DC 20552 · 800-842-6929 -Federal credit unions (words "Federal Credit Union" appear in institution’s name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 · 703-518-6360 -Banks that are state-chartered, or are not Federal Reserve System members Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC 20429 · 800-934-FDIC -Air, surface, or rail common carriers regulated by former Civil Aeronautics Board for Interstate Commerce Commission Department of Transportation Office of Financial Management Washington, DC 20590 · 202-366-1306 -Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 · 202-720-7051

DISCLOSURE AND AUTHORIZATION FORM—Please read carefully before signing the authorization

DISCLOSURE: In considering you for employment and, if you are presently employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Extra Credit Union may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency. For explanation purposes:
  • a "consumer report" is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and
  • an "investigative consumer report" is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information.
In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act ("FCRA"). Under the FCRA, before Extra Credit Union can obtain a consumer report, investigative consumer report or employer or non employer-related insurance or fidelity bond claims information about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in the report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

AUTHORIZATION

I have read and understand the foregoing Disclosure, and hereby authorize Extra Credit Union to obtain and rely upon consumer reports, investigative consumer reports, public government records and information regarding my involvement in any prior employer or non-employer-related insurance or fidelity bond claims in considering me for employment, and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize Extra Credit Union to obtain at their own cost and expense any such reports and information from third-party entities such as consumer reporting and insurance agencies and to share the reports and information received with any person involved in the employment decision about me. I also agree that this Disclosure and Authorization in its original, faxed, photocopied, or electronic (including electronically signed) form shall be valid for any consumer reports, investigative consumer reports, public record search, and employer or non-employer-related insurance or fidelity bond claim reports that may be requested about me by or on behalf of Extra Credit Union.

*Signature:
*Date:

 
 

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