Indiana

Application for Employment

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Equal access to programs, services and employment opportunities is available to all persons without regard to race, color, religion, sex (including
pregnancy, sexual orientation and gender identity), national origin, ancestry, age, disability, veteran status, genetic information, or any other
basis protected by federal, state, and/or local law.
In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations
for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include
making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording;
using a sign language interpreter; using specialized equipment; or modifying testing conditions.

Name___________________________________________________________________ Applicant ID #______________________

Last First Middle

Address___________________________________________________________________________________________________
Street City State ZIP Code
( )
Telephone #__________________ ( )
Cellular/Other Phone #_________________ E-mail Address_____________________________
/ /
Position(s) applied for______________________________________________________ Date of application___________________

Referral Source (e.g., Walk-in, Job Posting, Company’s Website, etc.)__________________________________________________________

AM
:
If necessary, best time to call you is..................... _______________ PM Will you work overtime if required?............................ Yes No
■ Home ■ Cellular/Other If no, please explain:________________________________
May we contact you at work?........................................ ■ Yes ■ No
If yes, work number and best time to call: _________________________________________________
AM
( )
_________________________________ :
_______________ PM Are you able to perform the “essential functions” of the job for which
If you are under 18 and it is required, you are applying (with or without reasonable accommodation)?
can you furnish a work permit?...................... N/A ■ Yes ■ No This question is not designed to elicit information about an applicant's disability. Please
do not provide information about the existence of a disability, particular accommodation,
If no, please explain:________________________________ or whether accommodation is necessary. These issues may be addressed at a later stage
to the extent permitted by law.
Have you submitted an application here before?....... ■ Yes ■ No
Yes No Need more information about the
If yes, give date(s) and position(s):______________________
job’s “essential functions” to respond
_________________________________________________ Driver’s license number required if driving may be required in the
Have you ever been employed here before?................ ■ Yes ■ No job for which you are applying:
If yes, give dates: From_____________ / / / /
To_______________ ____________________________________ State___________
Is this application a request for reemployment
Have you ever been bonded?........................................ Yes No
following an extended military leave of absence
from this company?................................................ ■ Yes ■ No Have you ever been convicted of a crime that has not been expunged
by a court? NOTE: Answering “yes” to this question does not constitute an automatic
If yes, additional information may be requested. bar to employment. Factors such as date of the offense, seriousness and nature of the
Are you lawfully authorized to work in the violation, rehabilitation and position applied for will be taken
into account. ........................................................................ Yes No
United States?.................................................................. ■ Yes ■ No
/ /
Date available for work.......................................... _______________ If yes, please provide date(s) and details:_________________
What is your desired salary range or hourly rate of pay? _________________________________________________
$________________________ Per__________________
_________________________________________________
Type of employment desired: ■ Full-Time ■ Part-Time
■ Educational Co-Op ■ Seasonal ■ Temporary Have you entered into an agreement with any former employer or
other party (such as a noncompetition agreement) that might, in any
Will you relocate if job requires it?.............................. ■ Yes ■ No way, restrict your ability to work for our company?.......... Yes No
Will you travel if job requires it?................................... ■ Yes ■ No If yes, please explain:________________________________
If they have been explained to you, are you able to meet the
_________________________________________________
attendance requirements of the position?.... ■ N/A ■ Yes ■ No

AN EQUAL OPPORTUNITY EMPLOYER

Page 1
 Employment History
Starting with your most recent employer, provide the following information.
Employer Telephone #

/ /
Month Year Month Year

( ) Dates employed: to

Street address City State Compensation (Starting)

■ Hourly ■ Salary $ per
Starting job title/final job title
Commission/Bonus/Other Compensation $
Immediate supervisor and title (for most recent position held) May we contact for reference? Compensation (Final)
■ Yes ■ No ■ Later ■ Hourly ■ Salary $ per
Why did you leave?
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.

What did you like most about your position?

What were the things you liked least about the position?

Employer Telephone #

/ /
Month Year Month Year
( ) Dates employed: to

Street address City State Compensation (Starting)

■ Hourly ■ Salary $ per
Starting job title/final job title
Commission/Bonus/Other Compensation $
Immediate supervisor and title (for most recent position held) May we contact for reference? Compensation (Final)
■ Yes ■ No ■ Later ■ Hourly ■ Salary $ per
Why did you leave?
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.

What did you like most about your position?

What were the things you liked least about the position?

Employer Telephone #

/ /
Month Year Month Year
( ) Dates employed: to

Street address City State Compensation (Starting)

Hourly Salary $ per

Starting job title/final job title
Commission/Bonus/Other Compensation $
Immediate supervisor and title (for most recent position held) May we contact for reference? Compensation (Final)
■ Yes ■ No ■ Later Hourly Salary $ per
Why did you leave?
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.

What did you like most about your position?

What were the things you liked least about the position?

Employer Telephone #

/ /
Month Year Month Year
( ) Dates employed: to

Street address City State Compensation (Starting)

Hourly Salary $ per

Starting job title/final job title
Commission/Bonus/Other Compensation $
Immediate supervisor and title (for most recent position held) May we contact for reference? Compensation (Final)
Yes No Later Hourly Salary $ per
Why did you leave?
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.

What did you like most about your position?

What were the things you liked least about the position?

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 Employment History (continued)
Explain any gaps in your employment, other than those due to personal illness, injury, or disability.______________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

If not addressed on previous page, have you ever been fired or asked to resign from a job?........................................................ Yes No

If yes, please explain: ________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Skills and Qualifications

Summarize any special training, skills, languages, licenses, and/or certificates that may assist you in performing the position for which you are applying:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Computer Skills (Include software titles and level of experience, such as basic, intermediate, or advanced.)
Word Processing__________________________ Level:______ Internet_________________________________ Level:_______
Spreadsheet______________________________ Level:______ Other___________________________________ Level:_______
Presentation _____________________________ Level:______ Other___________________________________ Level:_______
E-mail__________________________________ Level:______ Other___________________________________ Level:_______

Educational Background
Starting with your most recent school attended, provide the following information.
# of Years GPA
School (include City and State) Completed Major/Minor
Completed Class Rank
 Diploma
■ ■ GED
■ Degree_______________________
■ Certification___________________
■ Other_________________________
■ Diploma ■ GED
■ Degree_______________________
■ Certification___________________
■ Other_________________________
■ Diploma ■ GED
■ Degree_______________________
■ Certification___________________
■ Other_________________________
■ Diploma ■ GED
■ Degree_______________________
■ Certification___________________
■ Other_________________________

References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.
Relationship # of Years
Name Title to You Telephone E-mail Known

( )

( )

( )
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 Related Information
When answering these questions, please exclude any information that would reveal race, color, religion, sex (including pregnancy, sexual orientation and gender identity),
national origin, ancestry, age, disability, veteran status, genetic information, or other similarly protected status.

To what job-related organizations (professional, trade, etc.) do you belong?_________________________________________________

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

List special accomplishments, publications, awards, etc.________________________________________________________________

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

List any relevant volunteer work.__________________________________________________________________________________

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Is there any other job-related information you want us to know about you?_________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.
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 and to otherwise verify the accuracy of all information provided by me in this application, resumé,
or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful
and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant
from consideration for employment on any basis prohibited by applicable local, state, or federal law.
I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for
employment, it will be necessary for me to reapply and fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my
employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract
for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the
contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require
me to complete an I-9 Form in this regard.
I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal
information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with
an affiliate or third party is to be used solely to perform the services requested by the employer.
This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an
applicant from consideration for employment on the basis of his or her race, color, religion, sex (including pregnancy, sexual orientation and gender identity), national origin,
ancestry, age, disability, veteran status, genetic information, or any other protected status under applicable federal, state, or local law.
NOTE: This Company complies with Indiana law prohibiting smoking in enclosed areas within places of employment.
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) eliminate me
from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
/ /
Signature of Applicant___________________________________________________________________________________________________________ Date__________________

This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide
legal opinions on any specific facts or services. The information is provided with the understanding that any person or entity involved in creating,
producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult
©2020 ComplyRight, Inc. an attorney concerning your particular situation and any specific questions or concerns you may have.
A2179DL_IN Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.

Page 4
As part of the employment process, it may be necessary for the Garrett State
Bank to verify previous employment, school references, credit history or other
such records that may be available such as criminal or vehicle operation history.
Since we are in a business requiring confidence and public trust, it is necessary
that we employ individuals whose past background reflects these qualities.
Employment may be impacted with an unfavorable Credit Report, Bureau of
Motor Vehicles or Criminal background checks. If negative information is
obtained through one of these reports, we will provide you with a copy of the
report and give you the opportunity to discuss the situation with us prior to any
final actions being taken.

By signing below, I consent to allow the Garrett State Bank to obtain any report it
deems necessary to make an employment decision expressly information via
credit reports, disclosure of prior driving records through the BMV, and criminal
background check with any law enforcement agencies. The information obtained
by the Bank from any of these sources will be held in confidence and only be
used in making an employment decision.

Should I become an employee of the Garrett State Bank I acknowledge and

authorize the Garrett State Bank to obtain any of the above stated reports at
anytime during my employment with Garrett State Bank.

__________________________________________
Signed

__________________________________________
Name: First Middle & Last (printed)

__________________________________________
Address

__________________________________________
City, State, Zip

__________________________________________
Social Security Number