1. No category

VOLUNTARY APPLICANT SELF-IDENTIFICATION SURVEY
Paragon Bank is a federal government contractor. As a matter of policy as well as
applicable law, we are required to keep records and perform certain analyses of our
applicant pool by race, ethnicity, and gender. Such analyses are only possible if we
know the EEO profile of our applicants, so we request that you complete this survey and
return it to us promptly.
Although the information that applicants provide does not in any way affect their
prospects for employment and is, in fact, treated very confidentially, it is nevertheless
very important to us. For any statistical analysis to be meaningful we must have
information on as many applicants as possible and it is just as important to collect
this information from men and from non-minorities as it is to obtain it from
women and minority group members.
We appreciate that some applicants will find this request intrusive and we regret this.
However, please be advised that we are required by the government to keep such
records and perform such analyses. You may decline to disclose but your cooperation
will allow us to be accurate.
In addition, information on county and state of residence as well as on how you learned
about the vacancy you applied for will assist us in our recruitment efforts.
The categories listed below are those used by the U.S. Department of Labor.
NAME:
ZIP CODE:
COUNTY AND STATE OF RESIDENCE:
HOW DID YOU LEARN OF THIS VACANCY:
IF BY ADVERTISEMENT, PLEASE GIVE NAME AND DATE OF PUBLICATION:
POSITION APPLIED FOR (MUST BE SPECIFIED):
Check Only One
Male
Female
Decline to Disclose
White, not of Hispanic Origin
(includes persons of Middle East ancestry)
Black or African American
Hispanic or Latino (regardless of race)
Asian/pacific Islander
American Indian/Alaskan native
Two or more races
Decline to disclose
VOLUNTARY APPLICANT SELF-IDENTIFICATION SURVEY
Continued
I am: 1. A Disabled Veteran
Yes
No
2. An Armed Forces Service Medal Veteran
Yes
No
3. A Recently Separated Veteran
Yes
No
4. An Active Duty Wartime or Campaign Badge
(Other Protected) Veteran
Yes
No
Definitions:
1.
A Disabled Veteran means (i) 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 (ii) a person who was discharged or released from active duty
because of a service-connected disability.
2.
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 (61 Fed. Reg. 1209) at
http://www.opm.gov/veterans/html/vgmedal2.asp.
3.
Recently Separated Veterans 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.
4.
Active Duty Wartime or Campaign Medal (Other Protected) Veterans 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. For those with Internet access, the information required to make this
determination is available at http://www.opm.gov/veterans/html/vgmedal2.htm.
Information also may be obtained by sending an email to helpdesk@vets100.com or
by calling (301) 306-6752.
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires ______
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide
equal opportunity to qualified people with disabilities. (i) To help us measure how well
we are doing, we are asking you to tell us if you have a disability or if you ever had a
disability. Completing this form is voluntary, but we hope that you will choose to fill it out.
If you are applying for a job, any answer you give will be kept private and will not be
used against you in any way.
If you already work for us, your answer will not be used against you in any way.
Because a person may become disabled at any time, we are required to ask all of our
employees to update their information every five years. You may voluntarily self-identify
as having a disability on this form without fear of any punishment because you did not
identify as having a disability earlier.
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:
•
•
•
•
•
•
•
•
Blindness
Autism
Bipolar disorder
Post-traumatic stress
disorder (PTSD)
Deafness
Cerebral palsy
Major depression
Obsessive
compulsive disorder
•
•
•
•
•
•
•
Cancer
HIV/AIDS
Multiple sclerosis
(MS)
Impairments
requiring the use of a
wheelchair
Diabetes
Epilepsy
Schizophrenia
•
•
•
Please check one of the boxes below:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
Muscular
Missing limbs or
partially missing
limbs
Intellectual disability
(previously called
mental retardation)
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires ______
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.
(i) Section 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.
Employment Application
It is the goal of Paragon Bank to employ the highest quality employees available who assist the bank in its goal of
providing superior service to its customers and to retain these employees through application of fair policies and
generous benefits. Paragon Bank is an equal opportunity employer and will fairly consider all applicants for employment
without regard to race, creed, color, religion, gender, age, disability, veteran status, or genetic information. Those
applicants requiring reasonable accommodation to the application and/or interview process should notify Human
Resources.
In order to be considered for employment, this application must be completed in full. Please indicate the specific job title
for which you are interested in being considered. Individuals who express an interest in “any” position, or a generic title
will not be considered for employment.
Please provide us with the following information about yourself and your past employment history. All questions must be
answered completely. If you have a resume, please attach it to this application. Please mark any questions that do not
apply to you with “N/A.” Your answers will be used by Paragon Bank for the purpose of employment considerations only.
This application will be given consideration, but its receipt does not imply that the applicant will be employed.
Personal Data
Last Name:
First Name:
Middle Name:
State:
Zip:
Street Address:
City:
Daytime Phone:
(
)
Mobile Phone:
Evening Phone:
(
)
E-mail Address:
Social Security Number:
-
(
)
-
Have you worked under another name?
Yes
If Yes, Give Name:
No
Position Desired:
Salary Desired:
Check Type of Employment Desired:
Days Available:
Monday
Full Time
Tuesday
Part Time
Wednesday
Per Diem
Temporary
Thursday
Friday
Saturday
Hours Available:
How did you hear about this employment opportunity?
If employee, give name:
Are you willing to work out of town overnight?
Yes
No
Are you over the age of 18 years?
Yes
No
If hired, will provide documentation establishing your ability to work in the United
States (e.g. social security permit.)?
Yes
No
Do you hold a valid driver’s license?
Yes
No
Do you have a car or other reliable transportation available for work?
Yes
No
Other than traffic violations, have you ever been convicted of a crime (including
guilty pleas and/or nolo contendere pleas)? (A “yes” answer will not necessarily
prevent you from being hired.)
Yes
No
If yes, describe in detail (nature of crime, state and county of conviction, current status):
Educational Background
Education (please check the highest level attained):
Post Secondary:
Some College
School Name
Some High School
Associate’s Degree
School Location
High School graduate or GED
Bachelor’s Degree
Areas of Study
Master’s Degree
Doctorate
Degree(s) Obtained
1.
2.
3.
4.
School Comments:
Work Experience
Please start with the most recent position, furnish dates and explanations for each period of unemployment if one
month or more. This section must be filled out completely.
Name of employer and location:
Start Date: (Month/Day/Year):
Ending Date: (Month/Day/Year):
Job Title:
Supervisor’s Name:
Supervisor’s Phone Number:
Employment Type:
Full Time
Part Time
Full Time
Part Time
Full Time
Part Time
Hours/Week Worked:
Salary (Monthly):
Job Responsibilities:
Name of employer and location:
Start Date: (Month/Day/Year):
Ending Date: (Month/Day/Year):
Job Title:
Supervisor’s Name:
Supervisor’s Phone Number:
Employment Type:
Hours/Week Worked:
Salary (Monthly):
Job Responsibilities:
Name of employer and location:
Start Date: (Month/Day/Year):
Ending Date: (Month/Day/Year):
Job Title:
Supervisor’s Name:
Supervisor’s Phone Number:
Employment Type:
Hours/Week Worked:
Salary (Monthly):
Job Responsibilities:
References
Please list the following information for at least three individuals that are not related to you and who have known you for
at least three years who can confirm some or all of the information contained in this application and are familiar with
your reputation.
Name:
Address:
Phone Number:
Years Acquainted:
E-mail Address:
Name:
Address:
Phone Number:
Years Acquainted:
E-mail Address:
Name:
Address:
Phone Number:
Years Acquainted:
E-mail Address:
Applicant Statement
I certify that, to the best of my knowledge and belief, the answers given by me to the foregoing questions and
statements made by me in this application (and accompanying resume, if any) are correct and complete. I understand
that misrepresentation or omission of facts in this application may disqualify me from further consideration for
employment, and may result in my discharge from employment, if discovered at a later date.
I understand that if I am employed, my employment may be terminated at any time by either myself or Paragon Bank. I
agree that, should I be employed, said employment will be at-will and will not be governed by any contract, either
express or implied.
I hereby authorize Paragon Bank or its designee to contact any or all of my references and former employers to inquire
about my past job performance, education, personal character and any other topic deemed relevant by Paragon Bank.
I further agree that I will hold those individuals and entities who respond harmless for any information they provide as a
result of such contact, and release them from liability for the result of any such information.
I agree to furnish such additional information and complete such examinations as may be required to complete my
employment file. I also expressly consent to submit to any physical examination that may be required of me, including
drug and/or alcohol testing upon request both prior to and, if employed, during employment with Paragon Bank. If I am
employed, I understand and agree that I will be bound by the policies of Paragon Bank.
__________________________________________
Date
___________________________________________
Applicant Signature * By typing my name, I attest to the
accuracy and integrity of this document.
THIS APPLICATION EXPIRES 60 DAYS AFTER THE DATE OF THE APPLICATION. IF YOU WISH TO REAPPLY
AFTER 60 DAYS, YOU MUST COMPLETE ANOTHER APPLICATION.
Authorization to Obtain Credit
and Criminal/Background Report Information
From An Outside Source
By signing this document, I authorize Paragon Bank to obtain information regarding my
creditworthiness, standing, or capacity, character, general reputation, personal
characteristics, or mode of living from any outside source that regularly provides such
information.
This information may be obtained in the form of a Consumer Credit Report and/or a
Background Investigation. The information that may be verified during a Background
Investigation includes, but is not limited to, past employment verification, social security
number verification, criminal history inquiry, personal reference inquiries, and education
verification.
I understand that Paragon Bank may use information from such a report in making a
decision regarding my employment.
_________________________________________
typing my name, I agree to all of
Applicant Signature *theByabove
statements.
_________________________________________
Date
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer
reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell
information about check writing histories, medical records, and rental history records). Here is a
summary of your major rights under the FCRA. For more information, including information
about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer
Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
• You must be told if information in your file has been used against you. Anyone who uses a
credit report or another type of consumer report to deny your application for credit, insurance, or
employment – or to take another adverse action against you – must tell you, and must give you
the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file disclosure”). You
will be required to provide proper identification, which may include your Social Security
number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
• a person has taken adverse action against you because of information in your credit
report;
• you are the victim of identity theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from
each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
www.consumerfinance.gov/learnmore for additional information.
• You have the right to ask for a credit score. Credit scores are numerical summaries of your
credit-worthiness based on information from credit bureaus. You may request a credit score
from consumer reporting agencies that create scores or distribute scores used in residential real
property loans, but you will have to pay for it. In some mortgage transactions, you will receive
credit score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer
reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete or unverifiable information must be removed
or corrected, usually within 30 days. However, a consumer reporting agency may continue to
report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most
cases, a consumer reporting agency may not report negative information that is more than seven
years old, or bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency may provide information about
you only to people with a valid need – usually to consider an application with a creditor, insurer,
employer, landlord, or other business. The FCRA specifies those with a valid need for access.
• You must give your consent for reports to be provided to employers. A consumer reporting
agency may not give out information about you to your employer, or a potential employer,
without your written consent given to the employer. Written consent generally is not required in
the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
• You may limit “prescreened” offers of credit and insurance you get based on information
in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a
toll-free phone number you can call if you choose to remove your name and address from the
lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5678688.
• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a
user of consumer reports or a furnisher of information to a consumer reporting agency violates
the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have additional rights. For more
information, visit www.consumerfinance.gov/learnmore.
States may enforce the FCRA, and many states have their own consumer reporting laws.
In some cases, you may have more rights under state law. For more information, contact
your state or local consumer protection agency or your state Attorney General. For
information about your federal rights, contact:
TYPE OF BUSINESS:
CONTACT:
Consumer reporting agencies, creditors and others not listed
below
Federal Trade Commission: Consumer
Response Center – FCRA Washington, DC
20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks
(word “National” or initials “N.A.” appear in or after bank’s name)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks,
and federal branches/agencies of foreign banks)
Federal Reserve Board Division of Consumer
& Community AffairsWashington, DC 20551
202-452-3693
Savings associations and federally chartered savings banks
(word “Federal” or initials “F.S.B.” appear in federal institution’s
name)
Office of Thrift Supervision Consumer
Complaints Washington, DC 20552 800-8426929
Federal credit unions (words “Federal Credit Union appear in
institution’s name)
National Credit Union Administration 1775
Duke Street Alexandria, VA 22314 703-5194600
State-chartered banks that are not members of the Federal
Reserve System
Federal Deposit Insurance Corporation
Consumer Response Center, 2345 Grand
Avenue, Suite 100
Kansas City, Missouri 64108-2638
1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil
Aeronautics Board or Interstate Commerce Commission
Department of Transportation, Office of
Financial Management
Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921
Department of Agriculture Office of Deputy
Administrator – GIPSA Washington, DC
20250 202-720-7051