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State Employees’ Credit Union Application for Employment
We appreciate your interest in our organization. Please complete the application as fully as possible. Applicants are considered for available positions without regard to race, color,
religion, age, sex, sexual orientation, gender identity, national origin, genetic information, veteran status, disability or other classification protected by law. To be considered as an
applicant, you must designate the particular available position for which you are seeking employment.
Position applied for: Date of application:
Applicant source:
1 = Walk in
3 = Friend 5 = Advertisement 7 = School/College 9 = OtherExplain
(select one)
2 = Job Service
4 = Relative
6 = Employment Agency
8 = Job Posting
Personal Data
Last Name: First Name: Middle Initial:
Address: City: State: Zip:
Telephone Number: )
If employed and under 18, can you furnish a work permit?
Have you filed an application here before?
Have you ever been employed here before?
If yes, give date:
Have you ever been bonded?
Have you ever refused bond?
Are you legally eligible to work in the United States?
(SECU will require proof of citizenship or immigration status upon employment. SECU does not participate in the H1B or TN Visa programs.)
Do you have any relatives employed with the State Employees Credit Union? If yes, please list them and their relationship to you:
Your Job Requirements
Salary desired: When could you be available to begin work?
Are you willing to relocate anywhere in the state?
Can you travel if a job requires it?
Select desired type of employment:
The following conditions may be required at some point in a job assignment. If required, would you be willing to work:
a. shift work? c. a work schedule other than Monday through Friday?
b. overtime work? d. a rotational work schedule? e. fluctuating hours?
Education
High School Business/Technical School College Graduate School
School name
and location
Years completed
Diploma/Degree Earned
Activities & Offices List professional, trade business or civic activities and offices held.
(You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, disability, or other protected status.)
Work Experience
List the last three positions you have held beginning with the most recent, or all the positions held in the last three years. If you do not have enough space, you may give more complete
and detailed information on additional pages. Accuracy of dates and addresses is essential.
Present or Last Employer Description of Work
Address
Position Reason for Leaving
Dates of Employment
From:
To:
Starting Salary Final Salary Supervisor’s Name and Title Telephone No.
Present or Last Employer Description of Work
Address
Position Reason for Leaving
Dates of Employment
From:
To:
Starting Salary Final Salary Supervisor’s Name and Title Telephone No.
Present or Last Employer Description of Work
Address
Position Reason for Leaving
Dates of Employment From:
To:
Starting Salary Final Salary Supervisor’s Name and Title Telephone No.
Do you have any commitments to another employer or organization which might affect your employment with us?
If yes, please explain:
References Give name, address and telephone number of three references who are not related to you and who are not previous employers.
1.
2.
3.
Applicant’s Certification and Agreement Please read carefully before signing. Signature must be handwritten.
The information that I have provided on this application is complete and accurate to the best of my knowledge and subject to validation by the Credit Union. I understand that any misleading or incorrect statement or omissions may render it void, and if I am
employed, be cause for immediate dismissal at any time during my employment. I authorize all persons, schools, employers, and other organizations to provide the Credit Union with any relevant information that may be required to arrive at an employment
decision. I hereby release these employers and individuals from all liability for any damage incurred in furnishing such information. In processing this employment application, I understand that State Employees’ Credit Union will request that an investigative or
Credit Bureau report be prepared. This report will include a Criminal Record Report and may include information as to my character and general reputation. Each staff member must be approved and accepted for bonding by a surety company designated by the
Credit Union in order to continue employment. In signing this application I authorize the Credit Union to supply my employment record in whole or in part, and in confidence to any prospective employer, government agency, or other party with a legal interest. I
hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee
at any time with or without cause. I further agree to comply with all policies of State Employees’ Credit Union.
Signature of Applicant: Date:
SECU 441 (08/19)
PRE-OFFERVOLUNTARYSELF-IDENTIFICATION
EEO / AFFIRMATIVE ACTION INFORMATION
SECU provides equal employment opportunity to all qualified persons regardless of race, color,
religion, age, genetics, sex, sexual orientation, gender identity, national origin, disability, veteran
status or other classification protected by law. This policy is applied to all employment actions
including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff,
recall, termination, rates of pay or other forms of compensation and selection for training including
apprenticeship.
State Employees’ Credit Union is required by law to document demographic information of applicants
for affirmative action reporting. Completion of this form is voluntary, and participation or refusal of
participation will not affect the hiring decision.
Please complete the following and submit with your application.
Last Name: First Name:
Date:
Position Applied For:
GENDER
Male
Female
Decline to Self-Identify
RACE/ETHNICITY
Hispanic or Latino
If not Hispanic or Latino:
White
Black or African American
Native Hawaiian or Pacific
Islander
Asian
American Indian or Alaska
Native
Two or More Races
Decline to Self-Identify
VETERAN STATUS
I identify as one or more of
the classifications of
protected veteran listed
below
I am not a protected
veteran
Decline to Self-Identify
Signature:
Signature must be handwritten.
*See next page for EEOC Race/Ethnic identification category definitions and protected veteran classifications*
August 26, 2019
click to sign
signature
click to edit
EEOC/Race/EthnicIdentificationCategories
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish
culture or origin, regardless of race
White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the peoples of Hawaii, Guam, Samoa
or other Pacific Islands.
Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand and Vietnam.
American Indian or Alaska Native – A person having origins in any of the original peoples of North and South
America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races All persons who identify with more than one of the above five races.
Protected Veteran Classifications
A “disabled veteran” is one of the following:
·
a veteran of the US military, ground, naval or air service who is entitled to compensation (or who but for
the receipt of military retired pay would be entitled to compensation) under laws administered by the
Secretary of Veterans Affairs; or
·
a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such
veteran’s discharge or release from active duty in the US military, ground, naval or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the US
military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has
been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the US military,
ground, naval or air service, participated in a United States military operation for which an Armed Forces service
medal was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA the Uniformed Services Employment and
Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the
uniformed service, you may be entitled to be reemployed by your employer in the position you would have
obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Dept
of Labor’s Veterans Employment and Training Service (VETS) at 1-866-4-USA-DOL.
August 26, 2019
__________________________
__________________
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.
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To help us measure how well we are doing, we are asking you to tell us if
you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disabilities include, but are not limited to:
Blindness Autism Bipolar disorder Post-traumatic stress disorder (PTSD)
Deafness Cerebral palsy Major depression Obsessive compulsive disorder
Cancer HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair
Diabetes Schizophrenia Missing limbs or Intellectual disability (previously called mental
Epilepsy
Muscular
partially missing limbs retardation)
dystrophy
Please select one of the boxes below:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
Signature
Today’s Date
Signature must be handwritten.
click to sign
signature
click to edit
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
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Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at
www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.
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Addendum
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CONSUMER REPORT FOR EMPLOYMENT PURPOSES
I hereby authorize State Employees’ Credit Union to obtain a consumer report and a criminal
records search from a consumer reporting agency for employment purposes only. If I am hired
by the State Employees’ Credit Union, this authorization will be valid during my employment.
I also authorize FirstPoint to perform a criminal records search. I understand that FirstPoint
does not guarantee the accuracy or timeliness of the information obtained from other sources
and that FirstPoint will not be liable for any inaccuracy in the information obtained from other
sources that are included in the INSIGHT report.
Signature of Applicant: Date:
FOR INTERNAL USE ONLY
Account Number:
Name (Please Print):
Current Address:
Social Security Number:
Birth Date:
SECU 709 (Revised 07/07/16)
click to sign
signature
click to edit
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Addendum
Nationwide Mortgage Licensing System Disclosure
I agree to disclose if I have ever been registered with the Nationwide Mortgage Licensing
System (NMLS) and will provide my NMLS ID. I agree to disclose any administrative,
criminal or civil findings made by any government jurisdiction once I have been offered
employment. If I am hired by the State Employees’ Credit Union, this authorization will be
valid during my employment.
Signature of Applicant: Date:
07/07/16
click to sign
signature
click to edit
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