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Name

First

Middle

Last

Address

Street

City

State

Zip Code

Telephone # (ex. 603-555-1234)

Mobile/Beeper/Other Phone #

E-mail Address

Position(s) Applied For

May we contact you at work?

Yes No

Work Number

If you are not over 18 and it is required, can you furnish a work permit?

Yes No

Have you submitted an application here before?

Yes No

Give dates and positions:

Have you ever been employed here before?

Yes No

Give dates:

Date available for work

What is your desired salary?

Type of employment desired

Will you work overtime if required?

Yes No

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accomodation)?

This question is not designed to elicit information about an applicant's disablility. Please do not provide information about the existence of a disability, particular accomodation, or whether accomodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes No Need more information to respond

Have you ever been bonded?

Yes No

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pled “guilty” or “no contest” to, or been convicted of a crime?

Yes No

Please provide date(s) and details

Educational Background

Starting with your most recent school attended, provide the following information.

References

List name and telephone number of three business/work references

Employment History

Starting with your most recent employer, provide the following information. Please include a minimum of your most recent three employers.

I agree to the Terms and Conditions

Meredith Village Savings Bank is an Affirmative Action/Equal Opportunity Employer. Women and minority applicants encouraged.

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