References
*Please provide 3 professional references who know of your work experience.
Professional Reference 1
Professional Reference 2
Professional Reference 3
Voluntary Self-Identification Information
In an effort to satisfy our voluntary government affirmative action program record keeping and reporting requirements, we ask that you complete this data survey. The information concerning status as an individual with a disability and veteran status may also be used to help you take advantage of the Company's affirmative action program for individuals with a disability and covered veterans. Your cooperation is appreciated. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not affect your application, subject you to discharge or discipline, or any other negative personnel action. Information provided will be kept confidential in accordance with applicable regulations.
Gender
Male
Female
I choose not to disclose this information
Ethnicity
Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race)
Not Hispanic or Latino (if not Hispanic or Latino, please address race below)
I choose not to disclose this information
Race (do not respond if you selected Hispanic or Latino above)
Hispanic/Latino
White (Not Hispanic or Latino): a person having origins of any of the original peoples of Europe, the Middle East, or North Africa
Asian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
American Indian or Alaska Native (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino): all persons who identify with more than one of the above five races
I choose not to disclose this information
Veteran Status
Descriptions
The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran
Disabled Veteran
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 serviceconnected disability.
Recently Separated Veteran
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.
Active Duty Wartime or Campaign Badge Veteran
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.
Armed Forces Service Medal Veteran
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 awarded pursuant to Executive Order 12985.
Veteran Status
I am a Protected Veteran
I am not a Protected Veteran
I choose not to disclose this information
Confirmation of Understanding
I understand how to categorize a disability after reading the above information.
Disability Status (Please select one below)
Yes, I have a disability (or have a history/record of having a disability)
No, I don't have a disability (or a history/record of having a disability)
I don't wish to answer
Employee Application Authorization
Applicant Informed Consent and Release of Liability
Westbury Bank has a vital interest in maintaining safe, healthful and efficient working conditions for its employees. Being under the influence of drug or controlled substance on the job may pose a serious safety and health risk not only to the user but to all those who work with the user. The possession, use or sale of an illegal drug or controlled substance in the workplace also poses unacceptable risks for safe, healthful and efficient operation.
I UNDERSTAND that according to Westbury Bank's policy, if I am offered a position, I would be required to pass a clinically accepted drug test, administered or directed by Westbury Bank's authorized medical professional. I understand that this test would be a condition of employment.
THE PURPOSE of this analysis would be to determine the presence of drugs or other chemicals. All information derived from this test would be kept confidential and released only to those Company personnel with a need to know.
I CONSENT freely and voluntarily to provide a specimen for drug/chemical analysis should I be offered a position. I also consent to the release of the result(s) of this analysis to the Company. I hereby release Westbury Bank and the laboratory, their employees, agents and contractors from any liability whatsoever, arising from a future request to furnish a specimen, the testing of a specimen, and decisions concerning my employment based upon the results of the analysis.
I understand and agree that future circumstances, accidents, incidents or workplace conditions may arise which cause the Company to request a specimen for chemical analysis at that time.My signature is an acknowledgement that I have read and understand this document and Westbury Bank's Drug Free Workplace Policy.
Acknowledgement Statement
By checking this box, I acknowledge that I have read and understand the Applicant Informed Consent and Release of Liability
Employee Application Authorization
I certify that the facts set forth in this application are true, correct and complete without misrepresentations or omissions of any kind whatsoever. I authorize investigation of the statements I have made herein.
I hereby release from any and all liability all representatives of Westbury Bank for their acts performed in connection with evaluating my application, background, credentials and qualifications. I hereby further authorize any party (including the companies, schools and organizations listed in this application form) to release any information they may have about me to Westbury Bank, including all of my personnel records with prior employers. I also release all persons, companies, schools and organizations (and all persons connected with them) who provide such information to Westbury Bank from any and all liability for any damage for giving this information. I understand that if any of the information on this application form is discovered to be incorrect, false or misleading or if there are any misrepresentations or omissions of and kind whatsoever, then Westbury Bank may deny me employment or terminate my employment, and I agree that Westbury Bank shall not be liable in any respect if it does so.
I also understand that my employment at Westbury Bank is contingent upon the satisfactory completion of a drug screen, finger-printing results, and an investigation of my work record and references. I consent to a pre-employment physical examination and such future examinations as may be required by Westbury Bank, which may include drug screening.
I understand that if I am employed by Westbury Bank, any such employment is not binding on either party for any specific period of time. I further understand that no representative of Westbury Bank, other than the CEO or President, has any authority to enter into any agreement for employment for any specified period of time. Any such agreement must be in writing and signed by such officer. I understand that any other written or oral statement to the contrary, even if made by a supervisor, manager or officer of Westbury Bank, is invalid and should not be relied on by me. I understand that if employed I will be an employee-at-will and that either Westbury Bank or I may terminate that employment relationship at any time, for any reason, with or without notice.
Application Authorization
By checking this box, I acknowledge that I have read and understand the employee application authorization