58548 Emp_Application_11.13_Layout 1 11/26/13 12:28 PM Page 1
CITY & COUNTY CREDIT UNION
EMPLOYMENT APPLICATION
City & County Credit Union (CCCU) is an equal opportunity/affirmative action employer, dedicated to a policy of non-discrimination in employment on any basis. The application for
employment shall not be construed as a contract of employment. Employment with CCCU is based on the “at-will” doctrine, meaning that either the employee or the employer may
terminate the employment relationship at any time and for any reason. CCCU adheres to all applicable, local, state and federal employment laws. Please fill out application form
completely. Applications are active for 60 days.
PERSONAL INFORMATION
Last Name
First
Middle
Date
Present Street Address
City
State
Zip Code
Telephone Number
Work Number
Cell Number
Are you 18 years or older?
Yes
No
Are you a citizen of the United States?
Yes
No
Are you legally authorized to work in the United States
Yes
No
Proof of eligibility documention must be provided at time of hire as required by law.
EMPLOYMENT DESIRED
Position Preference
Do you want work:
Date Available for Work
Full-time
Part-time
Pay Expectations ($ per____)
Temporary
If part time, specify days and hours available
Have you applied for employment with our Credit Union within the last 12 months?
Have you ever been employed by City & County Credit Union?
Yes
Yes
No
No
(If yes, please provide your name of record, job title, and dates of employment)
EMPLOYMENT HISTORY
(Please start with your present or most recent position)
Name of Employer
Telephone Number
Position
Supervisor’s Name
Address
City
State
Zip Code
Dates Employed (M/Y)
Reason for Leaving
May we contact for a reference at this time?
Yes
Ending Salary
No
If no, reason:
Brief description of your work and responsibilities
11.13
58548 Emp_Application_11.13_Layout 1 11/26/13 12:28 PM Page 2
EMPLOYMENT HISTORY
(Continued)
Name of Employer
Telephone Number
Position
Supervisor’s Name
Address
City
State
Zip Code
Dates Employed (M/Y)
Reason for Leaving
May we contact for a reference at this time?
Yes
Ending Salary
No
If no, reason:
Brief description of your work and responsibilities
Name of Employer
Telephone Number
Position
Supervisor’s Name
Address
City
State
Zip Code
Dates Employed (M/Y)
Reason for Leaving
May we contact for a reference at this time?
Yes
Ending Salary
No
If no, reason:
Brief description of your work and responsibilities
Please account for any periods of unemployment 30 days or more in duration and/or part-time employment not listed
EDUCATION
Level
Name/City/State of School
Years Complete/Grade
High School
9
10
Technical/Vocational School
1
2
College University
1
2
3
Graduate School
1
2
3
Other
Special Certifications
11
Graduate?
12
Diploma/Degree?
Yes
No
Yes
No
4
Yes
No
4
Yes
No
58548 Emp_Application_11.13_Layout 1 11/26/13 12:28 PM Page 3
SPECIAL SKILLS/ADDITIONAL TRAINING
Please describe any special job-related skills and qualifications acquired from employment, other education or volunteer experience (Typing WPM, certifications, languages,
computer software, licenses, etc.)
MISCELLANEOUS
Has your employment with any employer ever been involuntarily terminated?
Yes
No
If yes, please identify the employer, date of termination and reason for termination
Have you ever had any bond coverage modified, revoked, or declined?
Yes
No
If yes, please provide the date and reason for the bond coverage change.
REFERENCES
Please provide the names of two business references who are not related to you. If you do not have any employment-related references, please list individuals who can comment
on your work skill.
Name
Phone Number
Years Known
1.
2.
APPLICATION FORM ACKNOWLEDGEMENT
In exchange for the consideration of my job application; I agree that:
Neither the acceptance of this application, nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, shall serve to create an actual implied contract of employment,
or otherwise change in any respect the employment-at-will relationship between City & County Credit Union and the undersigned. Both the undersigned and City & County Credit Union and its affiliates may end the employment
relationship at any time, without specified notice or reason. If employed, I understand the City & County Credit Union may unilaterally change or revise their benefits, policies and procedures at any time.
As a condition of hire, I agree to provide documents establishing proof of identity and employment eligibility in compliance with the Immigration Reform and Control Act of 1986, and as it may be amended from time to time.
I understand that I must be physically and mentally fit to perform the work for which I have applied.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts in this application is cause for dismissal at any time without any previous notice. I hereby give
City & County Credit Union permission to contact schools, previous employers (unless otherwise indicated), references and others, and hereby release City & County Credit Union from any liability as a result of such contact.
I also understand that City & County Credit Union maintains a high degree of company and member confidentiality due to the nature of its business. I agree to maintain the confidentiality of the company’s policies and members.
Applicant’s Signature
Date
City & County Credit Union is a member-owned financial cooperative. Every member has a voice, and their pooled resources make us strong and service diverse. We believe in treating each other, and our members, as equal and
important. Thank you for your interest in becoming one of our staff.
Please return application to: City & County Credit Union, Attn: Human Resources • 144 11th Street East, St. Paul, MN 55101-2380
651-225-2700 1-800-223-2801 www.cccu.com