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"Employee Referral" in the source box above please list our employees name in the "Referred By" box below.
To enable us to fully consider your particular skills and interests, please respond thoroughly and candidly to the questions below.
Employment offers are conditioned upon satisfactory proof of your identity and eligibility to work in the U.S.
Are you eligible to work in the U.S.?
Are you available to work overtime?
Available to work overtime?:
If hired can you furnish proof that you are over the age of 18?
Proof of over 18?:
Do you have any relatives employed by Citizens Business Bank?
Relatives at CBB?:
If yes, please name:
Relationship to you:
Have you previously applied for employment with Citizens Business Bank?
Applied at CBB before?:
If yes, when?:
Have you previously been employed by Citizens Business Bank?
Employed by CBB before?:
If yes, when?:
Employment History - Starting with your current or most recent employment, please account for all time during the past 7 years, including part-time, self-employment, summer employment, and full-time U.S. military service. You may also include any work performed on a volunteer basis, temporary work and paid internships. :
Unemployment Record - Account here for all intervals of unemployment during the past 7 years (if any) to the present time.:
Please complete all questions. Insert "Not Applicable" where appropriate.
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?
Able to perform duties?:
If no, describe the functions that cannot be performed.
If no, details:
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)
I. I understand that if hired, my employment can be terminated for any reason, with or without cause, at any time at the option of either Citizens Business Bank or myself. I understand that no manager, supervisor or representative of Citizens Business Bank has any authority to enter into any employment agreement, oral or written, for any specified period of time or to make any agreement contrary to the foregoing.
II. I understand any offer of employment may be subject to the following: satisfactory references, Employment, clearance of Department of Motor Vehicle Report, verification of auto insurance coverage, and/or credit checks, clearance of crime records and acceptance by the bonding company.
III. I also understand that the bonding requirements will include fingerprinting for criminal investigations.
IV. I hereby authorize and request any and all of my former employers and any other person, firm or corporation to furnish any and all information concerning any creditworthiness and personal background and I hereby release each such employer or other person, firm or corporation from any and all liability by reasons of furnishing the requested information. I understand that in connection with this application, a consumer report and/or an investigative consumer report may be requested whereby information is obtained through personal interviews with my neighbors, friends or associates or with others with whom I am acquainted or who may have knowledge with respect to my character, general reputation, personal characteristics and mode of living, and hereby authorize the procurement of any such report. I understand that, upon my request, I have the right to know if any such report was requested and, if so, the name and address of the consumer reporting agency that furnished such reports and in the case of a consumer investigative report, that I may inspect and receive a copy of such report by contacting such agency. I also understand that I have the right to receive a complete and accurate disclosure of the nature and scope of the information requested if I request such disclosure within a reasonable period of time.
V. I understand that during my employment, the Bank may, from time to time, take such steps as are necessary to ensure compliance with its drug testing policy. This includes searches of Bank property, employees and/or the personal effects of employees, and the administration of urine drug screens, or other appropriate medical tests. I understand that any employee who refuses a request to submit to a search of his or her person or property or who refuses to undergo such a medical test will be subject to disciplinary action up to and including termination.
VI. I understand that after an offer of employment has been made, but before commencement of employment, I will be tested for illegal drugs. The job offer will be contingent on successfully passing the drug test.
VII. I understand that Citizens Business Bank is a smoke-free employer.
VIII. I certify that the information in my application for employment and/or submitted resume is true, complete and accurate. I authorize Citizens Business Bank to verify the accuracy of the application and/or resume and to contact any person, company, agency, educational institution or other organization for that purpose. I understand that any misrepresentation or omission of facts is cause for recision of any employment offer or for termination.
If you would like a copy of a report obtained from such an agency, please indicate it here:
Copy of a Report:
Please type your full legal name in the "Electronic Signature" box below. This will serve as your agreement and understanding of the statements above.
Format: M/D/YY *
For Affirmative Action, EE01 and Veterans Reporting Purposes Only
As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.
To Applicants for Employment at Citizens Business Bank:
The federal Government requires us to keep statistics regarding the data below. The data is not used in any way to influence the selection process.
Choose Not to Disclose
Two or More Races
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - 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 (Not Hispanic or Latino) - 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 (Not Hispanic or Latino) - All persons who identify with more than one of the above five races. Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
Veterans Self-Identification Form
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:
A “disabled veteran” is one of the following:
a veteran of the U.S. 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 U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. 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 U.S. 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. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
I identify as one or more of the classifications of protected veterans
I am not a protected Veteran
Prefer not to answer
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
Candidate Individual with disabilities:
Voluntary Self-Identification of Disability
OMB Control Number
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Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do you know if you 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:
• Autism • Deaf or hard of hearing • Missing limbs or partially missing limbs • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Depression or anxiety • Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS) • Blind or low vision • Diabetes • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression • Cancer • Epilepsy • Cardiovascular or heart disease • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Celiac disease • Intellectual disability • Cerebral palsy Please Select one of the options below :
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don't Have A Disability, Or A History/Record Of Having A Disability
I Don't Wish To Answer
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.
For Employer Use Only Employers may modify this section of the form as needed for recordkeeping purposes. For example:
Job Title: _______________
Date of Hire: _______________