EMPLOYMENT APPLICATION

PLEASE DO NOT WRITE IN SHADED AREAS FOR OFFICE USE ONLY

PLEASE PRINT

Name:

Todays Date:

Address:
Phone:

Alt. Phone:

Email:

Expected
Wage/Salary:

per

Position Applying for:

How did you hear about
this position?

PLEASE PLACE A CHECK BY YOUR RESPONSE OR PROVIDE THE APPROPRIATE INFORMATION.

Have you ever been convicted of a felony, convicted of a misdemeanor involving dishonesty or moral turpitude,
or convicted in a military court martial? (A conviction will not automatically bar you from employment

YES
NO

If yes, please explain:

Are you legally eligible to work in this country?
YES NO
Have you ever been declined for bond coverage?
YES NO

Can you work at locations not accessible by public transportation?

YES NO
Have you ever had any bond coverage modified or revoked?
YES NO

IN ADDITION TO ATTACHING YOUR RESUME, please list your work experience below (last job first)
COMPANY NAME AND
LOCATION

POSITION/DUTIES

SALARY/WAGE

DATES EMPLOYED
FROM:
TO:

REASON FOR
LEAVING

SUPERVISOR/TITLE
PHONE NUMBER

RELEVANT EDUCATION (LIST TWO HIGHEST):

COLLEGE/SCHOOL & LOCATION

MAJOR

DEGREE/DIPLOMA
RECEIVED

OTHER EDUCATIONAL INFORMATION, Professional Certifications,

Affiliations and/or Licenses (indicate State and Date(s) if
applicable)
1.
2.
3.

Name

PERSONAL REFERENCES
(please list name, address, phone number, years of acquaintance and profession)
Address
Phone Number(s)
Profession

Title

Years of
Acquaintance

1.

2.

3.
Specialized Skills (Skills/Equipment Operated yrs experience)

PC/MAC ________ Word________ Excel ________ PowerPoint _______ Outlook _______

State any additional information you feel may be helpful to us in considering your application:

CERTIFICATE OF CANDIDATE (To Be Completed By All Candidates)

General: I have submitted the attached form to MSCU for the purpose of obtaining employment. I certify as to the accuracy of the matters set forth herein and in my resume and
understand that any misstatement of fact may cause me to be refused employment or to lose my employment. If employed, I further understand that my employment is not guaranteed
for any specific time and may be terminated at any time for any reason.
References: I hereby authorize MSCU and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be
necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I
specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form.
In Connecticut, effective October 1, 2002, an employment application form that contains any question concerning the criminal history of the applicant must contain a notice, in clear and
conspicuous language :
i.
ii.
iii.

that the applicant is not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o, or 54-142a;
that the criminal records subject to erasure pursuant to section 46b-146, 54-76o, or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with
service needs, an adjudication as a youthful offender, a criminal charge that has not been found guilty or a conviction for which the person received an absolute pardon; and
that any person whose criminal records have been erased pursuant to section 46b-146, 54-76o, or 54-142a shall be deemed to have never been arrested within the meaning of the general statues
with respect to the proceedings so erased and may so swear under oath.

NOTE: The portion of the employment application form which contains information concerning the arrest record or criminal history or an applicant (or employee) must not be available to any
employee or member of the company interviewing the applicant except to the personnel department. (If there is no personnel department, then to those in charge of the employment and those
involved in the interviewing.

SIGNED:___________________________________________________________________________
(Candidate)

MSCU is an Equal Opportunity Employer

DATE: __________________________________________

CONSENT TO DRUG/ALCOHOL TESTING

AND RELEASE OF RESULTS

Connecticut law provides that:

No employer may require a prospective employee to submit to a urinalysis drug test as part of the application
procedure for employment with such employer unless: (1) the prospective employee is informed in writing at the
time of application of the employers intent to conduct such a drug test; (2) such test is conducted in accordance
with the requirements of Sec. 31-51u(a); and (3) the prospective employee is given a copy of any positive
urinalysis drug test result. The results of any such test must be confidential and must not be disclosed by the
employer or its employees to any person other than any such employee to whom such disclosure is necessary
(Sec. 31-51v).
By this form, the applicant is informed of Mutual Security Credit Unions intent to perform a drug/alcohol test, and
authorizes Mutual Security Credit Union, and/or any agents of Mutual Security Credit Union, to conduct the test
and the testing facility to release the results.
I, ________________________________________________ do hereby consent to undergo a drug/alcohol test,
as required by Mutual Security Credit Union. Further, I authorize the hospital and/or testing agency, to release to
Mutual Security Credit Union the results of such test and I release the hospital, clinic, and/or testing facility, its
doctors, and medical personnel, and Mutual Security Credit Union and its employees from any liability arising
from this testing.
Signature:_____________________________________________ Date: ____________________
Thank you for completing an application form and for your interest in employment with Mutual Security Credit
Union. Employment will be subject to satisfactory results of background checks and drug/alcohol screening in
accordance with state and federal law. Mutual Security Credit Union is an Equal Opportunity Employer.

AUTHORIZATION TO RELEASE INFORMATION

I,
Last Name

First Name
Current Address

Middle Name
Dates Lived

Here
Addresses for the Past Seven Years: (include street, city, state, zip code)

Date of Birth
Social Security Number

Other Names Used (including maiden name)

Driver's License #

Dates of Residence:

Years Used
State

do hereby authorize verification of all information in my employment application from all sources of employment, education, motor
vehicle, financial history, criminal history, personal character, credit and worker's compensation records in accordance with ADA, labor
and wage records and the Fair Credit Reporting Act, etc. or any part thereof, and authorize any duly authorized agent of Mutual
Security Credit Union to obtain, whether the said records are public or private, and including those which may be deemed to be
privileged or confidential in nature and I release all persons from liability on account of such disclosures. Information appearing on this
Authorization will be used exclusively by Mutual Security Credit Union for identification purposes and for the release information
which will be considered in determining any suitability for employment. I certify that I have made true, correct, and complete answers
and statements on my employment application, any supplements to it and in any interview in the knowledge that they will be relied upon
in considering my application for employment. I agree to provide additional information that may be requested to process my
employment application. I authorize without reservation, any party or agency contacted by Mutual Security Credit Union to furnish the
above-mentioned information. This authorization is valid during the course of my employment to the extent permitted by law.
**I hereby do _______do not_________ authorize you to contact my current employer for Employment and Reference Verifications
(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the
Employment/Reference Section of your application.)
I have the right to make a request to Mutual Security Credit Union, upon proper identification, to request the nature and substance of
all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me
which Mutual Security Credit Union has previously furnished within the two year period preceding my request.
I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any
supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.
Printed Name

________________________________________
Applicant Signature

_______________
Date

CALIFORNIA, OKLAHOMA, and MINNESOTA RESIDENTS ONLY: If you are a current California, Oklahoma, or
Minnesota resident and would like to request a copy of your Consumer Report or Investigative Consumer Report, please check
the box. This report may include character and reputation information obtained through personal interviews.