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PO Box 716
Pago Pago,
American Samoa 96799
APPLICATION FOR EMPLOYMENT
APPLICANT TO COMPLETE ALL INFORMATION REQUESTED
PLEASE PRINT
In compliance with Federal and Territory equal employment opportunity, laws, qualified applicants are considered
for all positions without regard to race, color, religion, sex, national status, veteran status, non-job related
disability, or any other protected group status.
Date: ____________________
Name: ___________________________________________________ Social Security No.: ____________
First Middle Last
Present address: _________________________________________________________________________
P.O. Box Village City State Zip
Telephone Number: ( ) Email address: _____________________
Do you have a legal right to be employed in the Territory? Yes _____ (proof required) No ______________
Are you over the age of 18? _________________
GENERAL
Are you currently employed? __________ If not, when was your last day employed? __________________
Position applying for: ___________________ Full Time Part-Time Temporary
Who referred you?_____________________ Rate of pay expected: ________________________________
Date available:__________________________________________________________________________
Are you related to anyone presently employed by Territorial Bank of American Samoa?_______________
If yes: Name: _______________________________ Relationship: ________________________________
Name the computer programs which you are proficient in: _______________________________________
List any other qualifications (i.e.10 key, typing speed): _________________________________________
______________________________________________________________________________________
Have you ever been terminated or asked to resign? _____________________________________________
______________________________________________________________________________________
If yes, state employer, date, and complete circumstances: ________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
NOTE: FOR REGULATORY AND BONDING PURPOSES YOU MAY BE FINGERPRINTED AND A
BACKGROUND INVESTIGATION CONDUCTED REGARDING CRIMINAL RECORDS.
HAVE YOU EVER BEEN CONVICTED, SENTENCED TO, PARTICIPATED IN A PRE-TRIAL DIVISION
PROGRAM, OR PLEAD NO CONTEST IN CONNECTION WITH A CRIMINAL OFFENSE INVOLVING
DISHONESTY OR BREEACH OF TRUST? (Including, but limited to, shoplifting, robbery, embezzlement,
forgery, perjury, tax evasion, etc.)
If yes, please explain: __________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________