APPLICATION FOR EMPLOYMENT

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

All applications for position with this organization or any of its subsidiaries are reviewed solely with regard to their qualifications and without regard to race, color, age, religion, sex, national origin, disability sexual orientation or veteran's status.

NAME

HOME PHONE ()-

STREET ADDRESS

CELL PHONE ()-

CITY/STATE/ZIP

EMAIL

POSITION APPLYING FOR

EMPLOYMENT TYPE

HOW WERE YOU REFERRED FOR THIS POSITION

PREFERRED WAY TO BE CONTACTED

CRIMINAL RECORD:

An applicant for employment with a sealed record on file with the commissioner of probation may answer "no record" with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior for criminal prosecution.

A conviction record will not necessarily be a bar to employment. Factors such as age at time of the offense, seriousness and nature of the violation and rehabilitation will be taken into account.

Have you been convicted of a felony?

Within the past 5 years have you been convicted and/or incarcerated for a misdemeanor, other than a first conviction for drunkenness, simple assault, speeding, minor traffic violations, or disturbance of the peace?

Is there any reason to believe that you may not be able to be ?

Have you been employed here previously:

If yes, when?

Position

Have you ever applied for a position here previously:

If yes, when?

Position

Are you under 18 years of age?

Are you a citizen of the United States or legally permitted to work in this country?

Are you a United States military veteran?

EDUCATION:

EDUCATION	NAME/LOCATION	NO. OF YEARS COMPLETED	DIPLOMA OR DEGREE RECEIVED
High School
College
Trade Vocational
Graduate Work

EMPLOYMENT HISTORY:

List below the information requested starting with the present or most recent employer. You may include employment performed on a voluntary basis.

Please mark the check box to the right if you have never worked before:

Employer:

Address: (City/State only)

Phone No.:
()-

Dates: (Month/Year)

From

Job Title:

Name of Supervisor/Title:

May We Contact:

Base Salary/Wage: (Per Year)

Starting $

Final $

Describe Major Duties:

Reason For Leaving:

Employer:

Address: (City/State only)

Phone No.:
()-

Dates: (Month/Year)

From

Job Title:

Name of Supervisor/Title:

May We Contact:

Base Salary/Wage: (Per Year)

Starting $

Final $

Describe Major Duties:

Reason For Leaving:

Employer:

Address: (City/State only)

Phone No.:
()-

Dates: (Month/Year)

From

Job Title:

Name of Supervisor/Title:

May We Contact:

Base Salary/Wage: (Per Year)

Starting $

Final $

Describe Major Duties:

Reason For Leaving:

PLEASE DESCRIBE BELOW ANY SPECIFIC QUALIFICATION(S) OR CAREER OBJECTIVE(S) YOU POSSESS WHICH ENABLES YOU TO BE A SUITABLE CANDIDATE FOR THIS POSITION OR ANY POSITION AT THE BANK. YOUR RESPONSE MAY BE AN AMPLIFICATION OF A PREVIOUS SECTION.

DISCLOSURE STATEMENT:

I voluntarily consent to a thorough investigation of my past employment. I give this organization or any of its subsidiaries the right to investigate my background and release from all liability and responsibility to all persons, companies or corporations supply such information.

I understand that any false or incomplete answers or statements made in this application will be grounds for the Bank to fail to hire me, or to discharge me if I am hired.

I further understand that the Bank conducts mandatory drug testing of all applicants and that any offer of employment is subject to my successful completion of a drug test. If I refuse to submit to a pre-employment drug test I understand that my application for employment will not be processed further. I release the Bank from any and all liability for damages arising from my agreement to submit to the Bank's mandatory drug testing procedure.

Further, I understand that a job at the Bank entails significant financial accountability and access to sensitive financial information. I further understand that the Bank conducts mandatory credit checks of: (1) all applicants during the application process; and (2) all employees three (3) years after the date of commencement of employment. The Bank conducts these mandatory credit checks by requesting copies of applicants' and employees' consumer reports from consumer reporting agencies. I understand that my application for employment will not be processed further and/or any employment I am offered will be terminated unless I submit to the Bank's mandatory credit check procedure. In addition, I understand that my employment or continued employment may depend on the results of the credit check.

Therefore, I authorize the Bank to conduct a credit check by requesting consumer reports from a consumer reporting agency on two separate occasions: once during the application process and a second time three (3) years after the date I commence employment at the Bank, should I receive and accept an offer of employment from the Bank. I hereby authorize and request that the consumer reporting agency from which the Bank seeks my credit information furnish such information to the Bank. I hereby release the Bank and the consumer reporting agency from any and all liability for damages arising from furnishing the requested information.

I understand that, if I am employed by the Bank, such employment is at-will and may be terminated by the Bank or by me at any time, for any reasons. I further understand that the at-will nature of my employment cannot be changed except by a written contract, signed by the Bank's Chairman or President.

I Agree