First State Bank
Larned, Pratt & Iuka

 Date _______________________________

APPLICATION FOR EMPLOYMENT

DISCLOSURE STATEMENT

We sincerely appreciate your interest in seeking employment with The First State Bank & Trust Co. This application form is intended for use in evaluating your qualifications for employment.   This is not an employment contract.  Please answer all appropriate questions completely and accurately.  False or misleading statements made on this form or during the interview are grounds for terminating the application process or, if discovered after employment, terminating employment.  Testing of job related skills and for the presence of drugs in your system may be required prior to employment.

ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT DISCRIMINATION BECAUSE OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, MARITAL OR VETERAN STATUS, HANDICAP OR DISABILITY.  NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMATION TO BE USED FOR SUCH DISCRIMINATION.

I hereby acknowledge that I have read and understand the foregoing disclosure statement.

	            Signature of Applicant_______________________________

PERSONAL

Please answer every question.  This application is only good for 60 days.  If you wish to be considered in the future you must reapply.

(PLEASE WRITE PLAINLY)

Full Name___________________________________    Social Security No.________________

Street Address________________________________   Home Phone No. __________________

City, State, Zip Code ___________________________  Work Phone No.___________________

List states and counties of residence for the past seven years? 
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How were you referred to us? 

Have you been convicted of a felony in the past seven years?  Yes_____  No_____
If yes, please explain ____________________________________________________________________________________________________________________________________________________________
PLACEMENT

Type of work desired? ___________________________________________________________
Would you prefer temporary, part time, or full time? ___________________________________

NOTE:  Do not fill out any part of this section you believe to be non~job related.

For office, clerical and data transcription positions' please indicate practical experience with any of the following:
Typing Speed  ____________ Shorthand Speed __________  Proof Machine _______________
10 Key _______  Computer (Word/ WordPerfect/ Excel)________________________________
Please indicate other skills and aptitudes that you feel qualify you for a position with us: (you may wish to include activities and positions held in civic, community, and school organizations or professional societies).  ____________________________________________________________________________________________________________________________________________________________

EMPLOYENT HISTORY

Have you ever worked for us before?  Yes ___ No ___  If yes, From__________ To __________  Please list employment experience in chronological order with most recent employer first.
******************************************************************************
Most recent employer ______________________________________Phone No._____________
Address_________________________________________________ Supervisor_____________
Dates:   From______________ To ___________________________ Base Salary____________
Position ______________________________________________________________________
Reason for Leaving _____________________________________________________________
******************************************************************************
Second Most Recent Employer_______________________________Phone No._____________
Address_________________________________________________ Supervisor_____________
Dates:   From______________ To ___________________________ Base Salary____________
Position ______________________________________________________________________
Reason for Leaving _____________________________________________________________
******************************************************************************
Third Most Recent Employer  ________________________________Phone No._____________
Address_________________________________________________ Supervisor_____________
Dates:   From______________ To ___________________________ Base Salary____________
Position ______________________________________________________________________
Reason for Leaving _____________________________________________________________
*****************************************************************************
If presently employed, why do you desire to change position: ____________________________
May we contact your present employer?  Yes _______   No _______
May we contact your past employers?      Yes _______   No _______
Comments: ____________________________________________________________________
EDUCATION
Type of School	Name & Address of School	Last Year Completed	Year  Graduated	Major Course of Study and Degree Granted	

High School
		
1  2  3  4 			

College

1  2  3  4  	
		
Other (Special Training)		
1  2  3  4 	

Are you planning to pursue further studies?  Yes _____ No _____  If so, when, where and what courses? _____________________________________________________________________________________

REFERENCES
Name *                         Address                           Telephone               Yrs Known/Relationship
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*Include only individuals familiar with your work ability.  Do not include relatives.

PLEASE ATTACH A RESUME

THIS APPLICATION WILL RECEIVE CAREFUL CONSIDERATION BUT THE ACCEPTANCE OF IT FOR FILING AFFORDS NO ASSURANCE OF EVENTUAL EMPLOYMENT.

CERTIFICATION AND RELEASE
 
I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.  I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment.  I acknowledge that my 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 or without cause.  In the event of employment, I understand, also, that I am required to abide by all rules and regulations of the employer.

I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited, to, credit history, public record information, criminal history, etc. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from all liability for any damage whatsoever for issuing this information.  I also understand that the use of illegal drugs is prohibited during employment.  If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Date ___________________________ Signature of Applicant __________________________________

Additionally, I authorize the Bank to supply my employment record, in whole or in part and in confidence, to any prospective employer, government agency, or other party, with a legal or proper interest.

Date ___________________________  Signature of Applicant __________________________________