No Can you travel if a job requires it?<br><br> Yes No SEALED RECORD NOTICE Applicants having sealed conviction records on file with the Commission of Probation may answer cno d to the following: Within the past five years, have you been convicted of a misdemeanor? Yes No If yes, please explain_______________________________________________________________________________ ________________________________________________________________________________ Have you ever been convicted of a felony? Yes No If yes, explain.<br><br> ____________________________________________________________________________________ Are you a veteran of the United States military service? Yes No If yes, what branch? _______________________________________________________ Please describe any special skills or training acquired while in the service: ________________________________________________________________________________ Clear Form AN EQUAL OPPORTUNITY EMPLOYER INVITATION TO IDENTIFY FOR AFFIRMATIVE ACTION PURPOSES Savers Bank is committed to the employment and advancement of minorities, females, individuals with disabilities, and veterans.<br><br> If you fall into one of these protected classifications, we invite you to identify yourself and receive coverage under our Company 9s Affirmative Action Plan. You may inform us of your desire to benefit under the program at this time and/or any time in the future. Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity.<br><br> The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts. EEO RACE / ETHNIC CATEGORIES: Hispanic or Latino 3 A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture of origin regardless of race. White (Not Hispanic or Latino) 3 A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.<br><br> Black or African American (Not Hispanic or Latino) 3 A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) 3 A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) 3 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.<br><br> American Indian or Alaska Native (Not Hispanic or Latino) 3 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) 3 All persons who identify with more than one of the above rice races. Please check all that apply.<br><br> Race or Ethnic Identity Gender Veteran Status Hispanic or Latino White Black or African American Native Hawaiian or Pacific Islander Asian American Indian or Alaskan Native Two or More Races Male Female Vietnam Era Veteran Special Disabled Veteran Other Eligible Veteran HOW WERE YOU REFERED TO THIS JOB? Advertisement Employee Referral School / College Recruiter State job Service Employment Agency Temporary Agency Walk In Government Agency Other (Please Specify) ____________________________________________ EMPLOYMENT EXPERIENCE : Start with your present or last job. Include military service assignments and any verified work performed on a volunteer basis .<br><br> Exclude organization names which indicate race, color, religion, sex or national origin. Employer Work Performed Address Dates Employed: From To Job Title Supervisor Hourly Rate / Salary Starting Final Reason For Leaving May we contact your employer? Yes No Employer Work Performed Address Dates Employed: From To Job Title Supervisor Hourly Rate / Salary Starting Final Reason For Leaving May we contact your employer?<br><br> Yes No Employer Work Performed Address Dates Employed: From To Job Title Supervisor Hourly Rate / Salary Starting Final Reason For Leaving May we contact your employer? Yes No SPECIAL SKILLS AND QUALIFICATIONS Summarize special skills and qualifications acquired from employment or other experiences: ________________________________________________________________________________ REFERENCES Give the name, address and telephone number of three references who are not related to you. ________________________________________________________________________________ _______________________________________________________________________________ _____________________________________________________________________ Type of School Name of School Location Number of Years Completed Major & Degree High School College Graduate School Business or Trade school Professional School Special Honors or Licenses Held: It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or of future benefits by this organization.<br><br> I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written st atement supersedes any and all oral representations made by agents or representatives of this organization. I acknowledge that any other offer of employment is conditioned upon my passing a medical examination the sole purpose of which is to determine whether, with or without reasonable accommodation, I am capable of performing the essential functions of the job f or which I am hired: and I understand that said examination will include a screening for foreign substances.<br><br> AGREEMENT: I certify that the information on this application is true, complete and correct. I authorize Savers Bank to inves tigate my past employment, education and activities and I release from all liability all persons, companies and corporations supplying su ch information. I understand that false answers, statements or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.<br><br> ___________________________________________________________________________________________________________ Signature Date For Human Resource Department Use Only Arrange Interview: Yes No Date of Interview ____________________________ Remarks: ______________________________________________________________________________________ _______________________________________________________________________________________________ Employed: Yes No Date of Employment ____________________________ Job Title: __________________________ Hourly Rate/Salary ___________________ Dept ______________ By: ________________________________________________________________ Name and Title Date

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