Personal Information

Name:

Address:

Alternate Address:

Contact Information:

Personal Information

Computer Skills

(Please include software titles and years of experience.)

Education

High School:

College or University

Other Education

Employment History

Please list beginning with most recent employer.

References

List three character/personal references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED.

1. I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete. I understand that any false information, omissions, misrepresentations or misstatements of any information in my application, or disclosed by me during the application process, will be grounds for not hiring me, or if I am already employed, my immediate termination regardless of the timing or circumstances of discovery.
2. I authorize any of the persons or organizations referenced in this application to give JCB any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application or during the application process, and I release all such parties from all liability from any damages which may result from furnishing such information to you.
3. I understand this application remains current for only 90 days. At the conclusion of that time, if I have not heard from JCB and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
4. I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S. and the federal immigration laws require me to complete an I-9 Form in this regard.
5. I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended to me by JCB, that such employment with JCB is at-will, for no specified duration and may be terminated by either JCB or me at any time, with or without cause or notice, unless otherwise stated in a written agreement signed by JCB's President/CEO. I understand this application does not constitute an offer, guarantee, agreement or contract for employment for any specified period or duration for any particular terms, conditions or benefits of employment. I understand that no interviewer, employee, officer or other representative of JCB, other than the President/CEO, has any authority to enter into any agreement, oral or written for employment for a specified period of time or to make any agreement or assurance contrary to this acknowledgment/authorization.
6. I authorize JCB to take all other steps necessary to verify the accuracy of the information provided in the application or during the application process.
7. I acknowledge I may be required to complete additional documents to assist JCB in its investigation and determination of my suitability for employment.
8. I acknowledge I must meet certain pre-employment screening requirements, including drug testing as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of this drug screen will result in withdrawal of any offer of employment or termination of employment if already employed.

APPLICATION MUST BE SIGNED.
I certify that I have read, fully understand and accept all terms of the foregoing statements.

Authorization for Background Investigation

I have read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to the preparation of a consumer report and/or investigative consumer report by a consumer reporting agency, and to the release of such reports to JCB and its designated representatives and gents for the purpose of assisting JCB in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or other lawful employment purpose. I understand that if employed by JCB, my consent will apply throughout my employment or contract period.

I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.

In order to assist with any request for information, I supply the following:

CONSUMER DISCLOSURE AND AUTHORIZATION FORM
Pursuant to the Fair Credit Reporting Act

This is to notify you that in connection with your employment or application for employment, Jackson County Bank (JCB) may procure a consumer report or investigative consumer report on you for the purpose of determining your suitability for employment. In the event that information from the report may be utilized in whole or in part in making an adverse employment decision, prior to making an adverse decision, we will provide you with a copy of the report and a description in writing of your rights under the Fair Credit Reporting Act.

Please be advised any consumer report or investigative consumer report requested may include information as to your character, general reputation, criminal records, personal characteristics, educational history, credit history and mode of living. You have the right to request, in writing, within a reasonable time, more information about the nature and scope of the information requested as required by the Fair Credit Reporting Act.

This authorization shall remain valid and in effect during the term of your employment or contract. JCB reserves the right to run subsequent consumer reports and/or investigative consumer reports on an as-needed basis.

A summary of your rights under the Fair Credit Reporting Act is also being provided to you.

Summary of Rights Under the Fair Credit Reporting Act

A summary of your rights under the Fair Credit Reporting Act is available  here.

Commitment Expectations

Our mission at JCB is “Fulfilling dreams and goals is our job; building value for shareholders, employees, customers and communities is our responsibility.” Therefore, it is important that we hire employees with specific character traits that mirror our operating philosophy.

There are five core values at the HEART of our commitment to our employees, shareholders, customers and our communities.

These five values are:

• Honesty - Our team members and JCB customers rely on us to always choose the path of honesty and to follow through in a forthright, direct, clear, complete and sincere manner.
• Encouragement - To succeed, to excel and to make the very best of every situation requires the continuing encouragement of each other and JCB customers.
• Accountability - At JCB, we have an obligation and a willingness to accept responsibility for all our actions--every hour of every day.
• Respect - Every individual is important.  Our employees should be courteous to JCB customers and others we do business with and should demonstrate professionalism with our fellow team members and others.
• Teamwork - Together, all members of JCB work as a team, putting aside our personal priorities, in order to achieve our common goal.

The people we hire are committed to assuring that these five core values guide their daily interactions with each other and our customers.

JCB is proud to be known and set apart by "Extraordinary Service." The commitment of our employees to this line of service is the key to our success.

AFFIRMATIVE ACTION VOLUNTARY INFORMATION

Jackson County Bank (JCB) is an Equal Opportunity Employer. To assure full implementation of our equal employment opportunity policy, persons are recruited and hired without regard to race, color, gender, national origin, marital status, pregnancy, age, religion, disability, sexual orientation, gender identity, protected veteran status, or any other status or characteristic protected by law. Moreover, JCB is a federal contractor and maintains an Affirmative Action Plan to recruit, hire and promote qualified women and minorities in its workforce. To comply with government recordkeeping regulations, JCB offers its job applicants the opportunity to provide certain information on a confidential and voluntary basis that will be used to monitor the effectiveness of JCB's recruitment efforts. The information will not be considered as part of the application for employer and will be kept separate from your employment application. The information may be disclosed to government agencies or officials investigating compliance with the law. If you would like to participate, please complete this voluntary survey.

Applicant’s Invitation to Self-Identify As A Veteran

Jackson County Bank (JCB) 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. 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.

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 and was not dishonorably discharged.
• 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 award 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 absence from employment 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.

In an effort to comply with applicable requirements regarding government recordkeeping, reporting and other legal obligations, we invite you to complete this applicant data survey. Failure to provide information will not subject you to any adverse personnel decision or action. Your cooperation is appreciated. Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

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.

Voluntary Self-Identification of Disability

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 I know if I 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:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

ⁱSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

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.