Employment Application

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Personal and General Information

Date

Name

Social Security Number

Current Address

How Long?

Home Phone Number

Work Phone Number

Cell Phone Number

E-Mail Address

Previous Address

How Long?

City

State

ZIP

For the purpose of verifying prior employment and educational background, please indicate if you worked or attended school under any other name.

If yes, give name

Referral Source

Website

Site Name

Where did you see our ad?

Current/Former Employee

Name

Walk in

Other

Please describe

Does your present employer know of your plans to change employment?

Yes No

May we contact your present employer?

Yes No

Have you previously applied for employment or been employed with Impact Bank?

Yes No

If yes, previous job title

Supervisor

Department

Dates previously Employed or Applied

Are you related to any employees of Impact Bank?

Yes No

Name / Relationship

Position Requirements

Desired Position(s)

Desired Locations

Desired Salary

Desired Status

Full-Time Part-Time Temporary

Will travel if required or requested?

Yes No

Will work weekends if required or requested?

Yes No

Will work over‐time if required or requested?

Yes No

Will work varying shifts if required or requested?

Yes No

Educational Background

High School

GPA

Number of Years Attended

Did You Graduate Yes No

If no, number of years completed

College/University

GPA

Number of Years Attended

Did You Graduate Yes No

If no, number of years completed

Major/Minor

Technical School

GPA

Number of Years Attended

Did You Graduate Yes No

Course

Certificate

Graduate School

GPA

Number of Years Attended

Did You Graduate Yes No

Field of Study

Degree: Master Doctorate

Professional Courses Completed

Skills and Qualifications

Personal Computer Skills

Yes No

Please Describe Experience

Application (MS Word, Excel, etc.) Skills

Yes No

Please Describe Experience

Customer Service Skills

Yes No

Please Describe Experience

Cash Handling Skills

Yes No

Please Describe Experience

Math/Accounting Skills

Yes No

Please Describe Experience

Other Skills

Please Describe Experience

Employment Record

Starting with the most recent employer, list prior work experience for your last three positions. Include any U.S. Military or National Guard Service.

Employer 1

Company Name

Phone #

Position

From

Address

Supervisor

Final Salary

Reason(s) for Leaving

Currently Employed Resigned Terminated

Duties Performed

Employer 2

Company Name

Phone #

Position

From

Address

Supervisor

Final Salary

Reason(s) for Leaving

Currently Employed Resigned Terminated

Duties Performed

Employer 3

Company Name

Phone #

Position

From

Address

Supervisor

Final Salary

Reason(s) for Leaving

Currently Employed Resigned Terminated

Duties Performed

Please explain any gaps in employment of more than three months.

References

Provide the names and contact information for three non‐related individuals who are willing and able to provide a reference regarding your qualifications in a work related environment for the position for which you are applying.

Reference 1

Name

Address

Phone Number

E-Mail Address

Relationship

Reference 2

Name

Address

Phone Number

E-Mail Address

Relationship

Reference 3

Name

Address

Phone Number

E-Mail Address

Relationship

Resume

You may attach a resume to this form by using the button below.

General Information

Please answer the following question

Have you ever been convicted in any court, whether civilian or military of a violation of the law involving dishonesty or breach of trust as defined under Article 19 of the Federal Deposit Insurance Act?*

Yes No

Note: Conviction of a crime and/or court’s adjudication of guilt being withheld involving dishonesty or breach of trust will not necessarily bar you from employment.

If yes, please provide:

Offense

Date

City and State

Disposition of Case

Court Location

Any Rehabilitation

*Section 19 of the Federal Deposit Insurance Act (12 U.S.C. 1829) prohibits, without the prior written consent of the Federal Deposit Insurance Corporation (FDIC), a person convicted of any criminal offense involving dishonesty or breach of trust or money laundering (covered offenses), or who has agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense, from becoming or continuing as an institution‐affiliated party, owning or controlling, directly or indirectly an insured depository institution (insured institution), or otherwise participating, directly or indirectly, in the conduct of the affairs of the insured institution.

Conditions of Employment

I agree with the following:

Yes No

I certify that each of the answers given in this application is complete and true to the best of my knowledge and I understand that any misrepresentation or omission may preclude an employment offer or may result in termination of employment. I understand that as part of the Impact Bank selection process I may be requested to complete pre‐ employment written or computer skills testing to be considered for the position. I authorize Impact Bank to investigate all statements made in the application process and understand that consideration for employment is contingent on the completion of satisfactory background investigation. Nothing in this application is intended to create a contract between Impact Bank and me. If hired, I understand and agree that my employment, and the terms and conditions of my employment, may be terminated or changed by Impact Bank at any time with or without notice.

Please complete all required fields.

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