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HOOSIER HILLS CREDIT UNION
EMPLOYMENT APPLICATION

Note: This application is valid for One Year. If you wish
to be considered for employment after this One Year period,
a new application must be completed.

An Equal Opportunity Employer

PERSONAL INFORMATION		DATE:

Name:		SS#
Present Address: (Street, City, State and ZIP)
Permanent Address: (Street, City, State and ZIP)
Phone No:	Are you 16 years or older? Yes No
In order to permit a check of your work and education records, are there any other names that you have previously used? Yes No If yes, identify names and relevant dates:

Please list all previous places of residence (if different than current residence) for the past three years. (Use a separate sheet if more than three):
1.		How Long?
2.		How Long?
3.		How Long?

GENERAL EMPLOYMENT QUESTIONS

How Did You Learn About Us? Advertisement Friend Walk-In Web Site Employment Agency Relative Other

Position Applied For:		Date You Can Start:

Are You Employed Now?	If So May We Contact Your Present Employer?

Have you ever applied to or been employed by this Company before? If so, when?

Are you prevented from lawfully becoming employed in this country because of VISA or Immigration Status? Yes No (If "yes", please explain and also note that proof of citizenship or immigration status will be required upon employment).

Are you currently on "lay-off" status and subject to recall? (If "yes", please explain:)

Can you travel if the job requires it?		Do you have a valid driver's license?

If yes, please provide your license number and the State that issued it:

EDUCATION	Name and Location of School	No. of Years Attended	Did You Graduate?	Subjects Studied / Degree

Elementary
High School
College
Graduate / Professional
Trade, Business or Other
Subjects of special study or research work:

FORMER EMPLOYERS (Please give an accurate, complete full-time and part-time employment record. Include any job-related assignments and volunteer activities. Start with your current employer (or most recent employer if not employed) and account for all periods of unemployment. Use a separate sheet if necessary.)


1.	EMPLOYER
	ADDRESS
	POSITION
	SUPERVISOR
	REASON FOR LEAVING
	VOLUNTARY OR INVOLUNTARY TERMINATION?
	EMPLOYMENT DATES -- FROM TO
	WAGE / SALARY -- STARTING FINAL
	WORK PERFORMED


2.	EMPLOYER
	ADDRESS
	POSITION
	SUPERVISOR
	REASON FOR LEAVING
	VOLUNTARY OR INVOLUNTARY TERMINATION?
	EMPLOYMENT DATES -- FROM TO
	WAGE / SALARY -- STARTING FINAL
	WORK PERFORMED


3.	EMPLOYER
	ADDRESS
	POSITION
	SUPERVISOR
	REASON FOR LEAVING
	VOLUNTARY OR INVOLUNTARY TERMINATION?
	EMPLOYMENT DATES -- FROM TO
	WAGE / SALARY -- STARTING FINAL
	WORK PERFORMED


4.	EMPLOYER
	ADDRESS
	POSITION
	SUPERVISOR
	REASON FOR LEAVING
	VOLUNTARY OR INVOLUNTARY TERMINATION?
	EMPLOYMENT DATES -- FROM TO
	WAGE / SALARY -- STARTING FINAL
	WORK PERFORMED

QUALIFICATION FOR EMPLOYMENT

Except for vacations and holidays, how many workdays were you absent during the past calendar year?
0-5 days 6-10 days 11-15 days 16-20 days 21+ days

This Company has a policy of assuring that the work envoronment is free from harassment and discrimination. Have you ever been accused of sexual or other harassment or employment discrimination? Yes No
If yes, please explain.

What do you consider your greatest qualifications?

Describe any specialized training, apprenticeship, and skills and state where it was received; also describe any job-related extra-curricular activities.

List professional, trade, business or civic activities and offices held. (You may exclude membership, which would reveal gender, race, religion, national origin, age, disability or any other protected status.)

Other (list)

PERSONAL REFERENCES

(Give the names of three persons not related to you, whom you have known at least one year. Do not include any prior employer.)

	Name	Address	Relationship	Years Acquainted	Telephone Number
1.
2.
3.

OTHER

In case of Emergency Notify: Name Address Phone

Have you ever been convicted of a crime in any State (including felonies, misdemeanors, guilty pleas, or pleas of nolo contendere), other than minor traffic offenses: If so, please explain Note: A prior conviction will not necessarily bar you from employment; however the type of conviction and when it occurred will be considered.

If hired, would you be able to perform all functions and all necessary job assignments of the particular job for which you are applying? Yes No If "No", please explain:

CERTIFICATION

I hereby authorize the release of any employment data relevant to my employment with Hoosier Hills Credit Union (Company) for the purpose of an employment investigation. I authorize a thorough investigation of my past employment, activities, and background and agree to cooperate in such investigation, and release from all liability or responsibility all persons and corporations requesting or supplying such information. This investigation may also include a determination regarding whether I have a criminal record. I agree to submit to any lawful drug, alcohol, or other testing that may be required as a condition of employment or continued employment and understand that refusal to promptly submit and cooperate with such testing prior to or during the course of my employment will result in disqualification from consideration for employment or, if hired, termination. I fully understand that if employed, any misrepresentation or omission on this Application or any other Company record will result in dismissal, regardless of the date of discovery. I acknowledge that employment is also subject to a satisfactory review of my references. Neither this Application nor any statement made to me during the hiring process or thereafter shall be considered a contract of employment of any kind. Where such a contract is intended, I understand that it will be separately entered into and signed by the President of the Company. Absent such a contract, I understand that, if hired, my employment will be terminable-at-will, with or without cause or notice, that I am not being employed for any specified or definite period of time, and that this application is not and is not intended to be a contract, offer, statement or confirmation of or for continued employment. I understand that any employee handbook or manual does not represent an employment contract if I am hired and that the Company may alter, modify, amend, or terminate any of its policies and benefits, both as to active and retired employees.
Date: ___________________________	Signature: ___________________________________

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