Application for Position: INSTRUCTIONS Please complete all portions of this employment application to be considered for employment. If you require accommodation during the employment process, including assistance in the completion of this employment application, please let us know. COPOCO Community Credit Union is an equal opportunity employer. We do not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a six month period after submission to the credit union and only for the desired position. Consideration for employment after the six-month period requires completion and submission of a new application. PERSONAL INFORMATION Name (Last Name First) Have you ever used any other names? Yes No (for background and criminal conviction checks) If yes, please explain: Present Physical Address Apt. No City State Zip Present Mailing Address (if different than above) Apt. No City State Zip Phone Home: Work: Cell: Email Email: Social Security Number - - (for bondability and criminal conviction checks) Can you upon employment, submit verification of your legal right to work in the United States and proof of age? Yes No Note If offered employment you will be required to submit documentation required by the IRCA Have you ever been convicted of a crime or entered a pretrial diversion program to avoid a conviction? Yes No If yes, please list: DESIRED EMPLOYMENT *Position applying for: 0 Full-time Part-time Date you can start: Pay expected: $ Have you applied for work with us before? Yes No Where? When? Have you worked for us before? Yes No Where? When? Who referred you to us? Relative Employment Agency Newspaper Ad Friend State Employment Office College Placement Service Walk in Other Apart from religious services, will you be able to work all other times? Yes No *Note: If hired, you will be required to perform work as required by the credit union. EDUCATION BACKGROUND Types of School Name of school, City and State Major No. of years completed Did you Graduate? Degree or certificate High School Yes No Diploma GED Technical School Yes No College Yes No College Yes No Graduate School Yes No Other Yes No EMPLOYMENT Starting with your present or last job, provide complete employment history for the last 10 years. You must answer all questions and this employment history must be completed even if you submit a resume. Name of Employer Phone Number Street Address City State Zip Beginning Date of Employment Ending Date of Employment Position Title and Duties Reason for leaving Supervisor’s Name May we contact this employer? Yes No, explain Name of Employer Phone Number Street Address City State Zip Beginning Date of Employment Ending Date of Employment Position Title and Duties Reason for leaving Supervisor’s Name May we contact this employer? Yes No, explain Name of Employer Phone Number Street Address City State Zip Beginning Date of Employment Ending Date of Employment Position Title and Duties Reason for leaving Supervisor’s Name May we contact this employer? Yes No, explain REFERENCES Please provide the names of three persons you are not related to, you have known at least one year and whom we may contact. Name Address Yrs. known Phone Number JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS Summarize your job skills, training and/or study that are relevant for the desired position. Also, explain any periods that you were not working. AUTHORIZATIONS AND ACKNOWLEDGEMENTS I certify that the information contained in this application (and resume, if applicable) is true and complete. I understand that falsification or omission of relevant facts in my application, resume, and other materials provided, during my interview, or during my employment, if hired, in any detail, is grounds for disqualification from further consideration or for discipline or dismissal from employment in accordance with Credit Union policy. I agree to conform to the rules and regulations of the Credit Union, and understand that my employment relationship with the Credit Union is “at-will” and that I or the Credit Union may terminate my employment with or without cause, and with or without notice, at any time. I further understand that no agent or representative of the Credit Union has any authority to enter into a contract of employment with me except for the Credit Union President, and that any such agreement must be signed by the Credit Union’s President. I further acknowledge and agree that any dispute or claim against the Credit Union that I may have that arises from my employment must be filed within 180 days of the occurrence giving rise to the dispute or I will waive my right to pursue the claim and any damages or remedy. I acknowledge that any offer of employment I may receive from COPOCO Community Credit Union is contingent on the results of a reference and background check. Therefore, I authorize the Credit Union to: (1) investigate the truthfulness of all statements made on this application, or my resume; (2) contact my former employers and other listed references or any other persons who can verify information (including law enforcement agencies); and (3) discuss results of any investigation with other employees of the Credit Union involved in the hiring process. In addition, I give my consent for all contacted persons, including former employers, to provide information concerning this application and I release each such person from liability for providing information to the Credit Union. I waive any written notice for the release of any information, including my discipline history, which may be required under state or federal law. I hereby give my consent for COPOCO Community Credit Union through an authorized agent to collect my urine, saliva, blood, or hair samples for the purposes of testing for the presence, and my use of, alcohol, drugs, or other controlled substances. I hereby release COPOCO Community Credit Union and its authorized collection/testing agent from any liability whatsoever, including attorneys’ fees, from any liability resulting from the collection or testing process or from the tests results. I further understand that should I receive an offer of employment, it may be conditioned upon my undergoing and successfully passing a medical examination. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug test, or medical examination at any time at the discretion of COPOCO Community Credit Union. I hereby consent to having the results of any such alcohol or drug test or medical examination disclosed to COPOCO Community Credit Union. I also acknowledge that any offer of employment that I receive is contingent upon the results of my alcohol and drug test being negative and my medical examination finding me able to perform the essential functions of the job offered with or without accommodation. I understand that a positive drug test result, a refusal to submit a requested sample for testing, or a refusal to authorize such testing may result in the Credit Union withdrawing any offer of employment made to me, or result in my immediate discipline or dismissal. Should I have a legally protected physical or mental disability that affects my ability to perform the job that I seek, I understand that I may request that the Credit Union provide a reasonable accommodation for it. I am aware that under Michigan’s Persons with Disabilities Civil Rights Act I must make any request for accommodation immediately known and no later than 182 days after the date that I know, or reasonably should have known, of my need for an accommodation. I understand; however, that my failure to request an accommodation under Michigan law does not waive any right that I may have to request an accommodation under the federal Americans with Disabilities Act of 1990. Security Code: What's this? 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