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Employment Application

Please enter all requested information in the application form below.

All information marked (*) is required

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Personal Information

First Name:

Middle Name:

Last Name:

Former Name:

Email Address:

Home Phone:

Mobile Phone:

Social Security Number:

Street Address:

City:

State:

Zip Code:

Employment Eligibility

Are you eligible for employment in the USA?

Yes No *

If no, what is your visa status?

If under 18 years of age, state birth date:

Do you have any relatives or friends that are employed at 1st MidAmerica?

Yes No

If so, please list:

Have you ever worked for 1st MidAmerica before?

Yes No

If so, when?

Have you ever applied for a position at 1st MidAmerica before?

Yes No

Mortgage Registry Number
(if applicable)

Position

Specific position(s) for which you are applying:

How did you learn about us?

website newspaper friend/relative current member

Date Available

Salary Desired

Employment Preference

Full-time Part-time Either

Are you available

morning afternoon anytime

Please select all branches you would be willing to work at:

Bethalto
East Alton
Alton
Godfrey
Jerseyville
Wood River

Education Background

Educational Background:
(Check highest level completed)

Place	Name/Address	Major Course/Subject	Last Year Completed	Did you Graduate?	Degree
High School:			1 2 3 4	Yes No GED
College /Other:			1 2 3 4	Yes No

Are you currently pursuing further studies?

Yes No
If yes, what is your major area of study and what school you are attending?

What is your current school schedule?

Employment History

Please list below present and past employers, beginning with the most recent.
Please complete all information and be specific.

Employer 1

Company:	Address:	Telephone:
Dates Employed: From: To:	Salary: Starting: Leaving:	Name of Supervisor:
Your Title and Duties:
Reason for Leaving:

Employer 2

Company:	Address:	Telephone:
Dates Employed: From: To:	Salary: Starting: Leaving:	Name of Supervisor:
Your Title and Duties:
Reason for Leaving:

Employer 3

Company:	Address:	Telephone:
Dates Employed: From: To:	Salary: Starting: Leaving:	Name of Supervisor:
Your Title and Duties:
Reason for Leaving:

May we contact the above employers for reference checking purposes?

Yes No
Please identify by number any employer you do not wish us to contact: e.g. Employer 1, Employer 2, etc.

Personal Computer Experience

Select any technical or software skills you may have.

typing/keyboarding
spreadsheet
email
10 key/adding machine
word processing

Other (please list)

Personal References:

Please list names, addresses, and phone numbers of two personal references,
excluding relatives and former employers.

1. Name:
Phone:
Address:

2. Name:
Phone:
Address:

Interests:

Please use the space provided below to describe your interest in 1st MidAmerica Credit Union and the skills, aptitudes and special training that you feel qualify you for a position with us.

Federal law prohibits a federally insured credit union from employing a person who has been convicted of a crime of dishonesty or breach of trust, or has entered into a pretrial diversion program, absent prior approval from the federal regulator. I understand I am not required to provide 1st MidAmerica Credit Union with any information about sealed or expunged conviction or arrest records.

Please identify whether you have been convicted of any of the following crimes during the last ten years:

Yes   No    receiving or claiming gifts for procuring loans;
Yes   No    theft, embezzlement or misappropriation of money, funds or securities;
Yes   No    falsifying bookkeeping entries for loans in exchange for compensation;
Yes   No submitting false, forged or counterfeit statements or documents to NCUA;
Yes   No    knowingly concealing assets from NCUA liquidating agent;
Yes   No fraud
Yes   No obstructing exam of financial institution by federal agency;
Yes   No    money laundering
Yes   No monetary transactions in property derived from specific unlawful activity; and/or
Yes   No participation in pretrial diversion program
Yes   No caused a financial services-related business license to be suspended, revoked or restricted

Have you ever been asked to resign or been discharged from employment?

Yes No

If yes, please explain:

PLEASE READ CAREFULLY BEFORE SIGNING
1ST MIDAMERICA is an equal opportunity employer. 1ST MIDAMERICA does not discriminate in employment and no question on the employment application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state or federal law. .

I understand that by completing this application, 1ST MIDAMERICA does not guarantee a job interview or an offer of employment. If employed, I understand that my employment is for no definite period of time and can be terminated at any time and for any reason by either 1ST MIDAMERICA or me.

I have read and agree to the above and hereby certify that the facts I provided in my employment application are true and complete. If I misrepresent or deliberately leave out a fact in my application, I may be disqualified from further consideration or if employed, I may be dismissed immediately.

Applicant's Signature: Date Signed:

AUTHORIZATION
WARNING: PLEASE READ CAREFULLY

I have received the written disclosure verifying that 1st MidAmerica Credit Union obtains consumer reports for employment purposes. I acknowledge 1st MidAmerica Credit Union has my authorization to conduct a credit report and obtain a consumer report from a consumer reporting agency (including credit bureau) on my credit history and credit standing which will be used for employment purposes only. 1st MidAmerica Credit Union obtains investigative reports to obtain information as to my character, general reputation, personal characteristics, and mode of living for employment purposes. In the event I am denied employment in whole or in part, or suffer an adverse employment action because of information contained in the consumer report and investigative report, 1st MidAmerica Credit Union will advise me of the adverse action and supply me with a copy of the report(s), and provide me with a summary of my rights, which will be obtained from the consumer reporting agency. I acknowledge a favorable credit history does not guarantee or ensure employment eligibility or continuance of employment.

Applicant's Signature: Date Signed:

Your savings federally insured to at least $250,000 by the National Credit Union Administration. An additional $250,000 is privately insured by ESI.

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