Section I. Application Information

Applicant Name:

Street:

City:

State:

Zip Code:

Telephone:

E-mail address:

Position Applying For:

Desired Salary:

Are You Seeking Full-Time or Part-Time Employment?
Full-Time Part-Time

Have You Previously Applied to this Company?
Yes No

Position:

When:

Have You Ever Been Convicted of a Felony?
Yes No

Note: Conviction of a felony will not necessarily disqualify you for employment. Do not include sealed or expunged convictions.

If You Answered “Yes” tothe Question Above, Please Explain:

Section II. Employment History

May We Contact Your Current Employer:
YesNo

List Most Recent Employer First:

From-To Date:

Name and Address of Employer:

Position/Duties:

Starting and Ending Salary:

Supervisor Name and Telephone No.:

Reason For Leaving:

Other Employers:

From-To Date:

Name and Address of Employer:

Position/Duties:

Starting and Ending Salary:

Supervisor Name and Telephone No.:

Reason For Leaving:

From-To Date:

Name and Address of Employer:

Position/Duties:

Starting and Ending Salary:

Supervisor Name and Telephone No.:

Reason For Leaving:

Section III. References

Name:

Business/Title:

Address :

Telephone:

Relationship:

Years Acquainted:

Name:

Business/Title:

Address :

Telephone:

Relationship:

Years Acquainted:

Name:

Business/Title:

Address :

Telephone:

Relationship:

Years Acquainted:

Section IV. Education/Skills

High School

Name and Location of School:

Years Completed:

Subjects Studied and Degree/Diploma Received:

College

Name and Location of School:

Years Completed:

Subjects Studied and Degree/Diploma Received:

Trade or Correspondence School

Name and Location of School:

Years Completed:

Subjects Studied and Degree/Diploma Received:

List Other Skills or Certificates You Hold:

How Did You Hear About Haverhill Cooperative bank?
Select One Advertisement Web Site Agency School Phone Inquiry Employee Referral

Certification and Authorization

By clicking “Submit” below, I certify that the information and answers given by me on this application, as well as any other information furnished by me in connection with my application for employment, are truthful, accurate and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would affect this application unfavorably. I authorize the Company and its representative to make any inquiry or investigation that it may deem desirable pertaining to the answers, information and references given by me, and to secure additional job-related information about me. I authorize my present employer, if any, and each of my prior employers to provide any such information regarding my employment and its termination from the Company. I release from liability the Company and its representatives for seeking such information, and all other persons, corporations, or organizations for furnishing such information.

I understand that any misrepresentation, inaccuracy or omission made by me in connection with this application may disqualify me for employment by the Company and may subject me to discharge if it is discovered after I have been employed by the Company. I ALSO UNDERSTAND THAT, IF HIRED, I WILL BE AN EMPLOYEE-AT-WILL AND WILL BE FREE TO RESIGN AT ANY TIME, AND THAT THE COMPANY LIKEWISE IS FREE TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I FURTHER UNDERSTAND THAT NEITHER THIS APPLICATION, NOR ANY OTHER COMMUNICATION FROM THE COMPANY IS INTENDED TO CREATE AN EMPLOYMENT CONTRACT AND THAT NO REPRESENTATIVE OTHER THAN THE PRESIDENT HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY.