1
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: __________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
2
LIST ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH MOST RECENT
COMPANY NAME:
____________________________________________________
ADDRESS, CITY, STATE, ZIP:
____________________________________________________
PHONE NO.:
____________________________________________________
NAME OF SUPERVISOR:
____________________________________________________
Base Gross Income:
$
DATES: From: To:
____________________________________
POSITION(S) HELD:
____________________________________
DUTIES /RESPONSIBILITIES:
____________________________________
REASON FOR LEAVING:
Starting Wage:
$
Per Hour Year
Ending Wage:
$
Per Hour Year
Bonus
Incentives
Amounts Received:
$
Hours Worked:
COMPANY NAME:
____________________________________________________
ADDRESS, CITY, STATE, ZIP:
____________________________________________________
PHONE NO.:
____________________________________________________
NAME OF SUPERVISOR:
____________________________________________________
Base Gross Income:
$
DATES From: To:
____________________________________
POSITION(S) HELD:
____________________________________
DUTIES /RESPONSIBILITIES:
____________________________________
REASON FOR LEAVING:
Starting Wage:
$
Per Hour Year
Ending Wage:
$
Per Hour Year
Bonus
Incentives
Amounts Received:
$
Hours Worked:
3
EDUCATIONAL BACKGROUND
Type of School Name and City Degree Earned Course or Major
College/University:
Technical School:
High School:
Other:
PROFESSIONAL REFERENCES
NAME: YEARS
KNOWN
RELATIONSHIP AND TITLE:
COMPANY:
HOME PHONE:
WORK PHONE:
WORK ADDRESS, CITY, STATE:
NAME: YEARS
KNOWN
RELATIONSHIP AND TITLE:
COMPANY:
HOME PHONE:
WORK PHONE:
WORK ADDRESS, CITY, STATE:
APPLICANT MUST READ AND SIGN
By my signature below, I authorize Territorial Bank of American Samoa to investigate all references and
to secure additional information about me if job related.
I certify that I have read and understood all of this employment application. It is agreed and understood
that the employer or his agents may investigate my background to ascertain any and all information of concern to
my employment history, whether same is of record or not, and I release employers and other persons named herein
from all liability for any damages on account of furnishing such information. I understand that, as an applicant for
a position with this bank, I may be asked to demonstrate that I am capable of performing tasks which are pertinent
to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination,
drug test, and background investigation.
I further certify that I am a genuine applicant for employment and this application is being submitted
solely for the purpose of seeking employment with the employer and for no other reason.
I agree to furnish such additional information and complete such examinations as may be required to complete my
employment file.
I also understand that misrepresentation or omission of information or facts may result in my rejection or
dismissal if hired. I agree to abide by all the rules and policies of the employer.
This certifies that this application was completed by me, and that all entries on it and information in it are
true and complete to the best of my knowledge.
Applicant Signature:________________________________________ Date:_____________________
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signature
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