MSCU Employment Application 5-1-10 | Criminal Record | Background Check




Today’s Date:


Alt. Phone:





Position Applying for:
How did you hear about
this position?

Have you ever been convicted of a felony, convicted of a misdemeanor involving dishonesty or moral turpitude,
or convicted in a military court martial? (A conviction will not automatically bar you from employment

 NO

If yes, please explain:
Are you legally eligible to work in this country?
 YES  NO
Have you ever been declined for bond coverage?
 YES  NO

Can you work at locations not accessible by public transportation?
 YES  NO
Have you ever had any bond coverage modified or revoked?
 YES  NO

IN ADDITION TO ATTACHING YOUR RESUME, please list your work experience below (last job first)






Specialized Skills (Skills/Equipment Operated – yrs experience) PC/MAC ________ Word________ Excel ________ PowerPoint _______ Outlook _______ State any additional information you feel may be helpful to us in considering your application: CERTIFICATE OF CANDIDATE (To Be Completed By All Candidates) General: I have submitted the attached form to MSCU for the purpose of obtaining employment. then to those in charge of the employment and those involved in the interviewing. years of acquaintance and profession) Address Phone Number(s) Profession Title Years of Acquaintance 1. I certify as to the accuracy of the matters set forth herein and in my resume and understand that any misstatement of fact may cause me to be refused employment or to lose my employment. Affiliations and/or Licenses (indicate State and Date(s) if applicable) 1. effective October 1. NOTE: The portion of the employment application form which contains information concerning the arrest record or criminal history or an applicant (or employee) must not be available to any employee or member of the company interviewing the applicant except to the personnel department. 54-76o. the records of which have been erased pursuant to section 46b-146. I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. 2002. schools. services or other entities listed by me in this form. and that any person whose criminal records have been erased pursuant to section 46b-146. an employment application form that contains any question concerning the criminal history of the applicant must contain a notice. 54-76o. 2. or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs. Name PERSONAL REFERENCES (please list name. Professional Certifications. a criminal charge that has not been found guilty or a conviction for which the person received an absolute pardon. iii. or 54-142a shall be deemed to have never been arrested within the meaning of the general statues with respect to the proceedings so erased and may so swear under oath. References: I hereby authorize MSCU and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. 2. or 54-142a. 3. ii. (If there is no personnel department. address. 3. SIGNED:___________________________________________________________________________ (Candidate) MSCU is an Equal Opportunity Employer DATE: __________________________________________ . an adjudication as a youthful offender. If employed. that the applicant is not required to disclose the existence of any arrest. in clear and conspicuous language : i. individuals. In Connecticut. 54-76o. criminal charge or conviction. phone number.RELEVANT EDUCATION (LIST TWO HIGHEST): COLLEGE/SCHOOL & LOCATION MAJOR DEGREE/DIPLOMA RECEIVED OTHER EDUCATIONAL INFORMATION. I hereby release employers. and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools. that the criminal records subject to erasure pursuant to section 46b-146. businesses.

to release to Mutual Security Credit Union the results of such test and I release the hospital. ________________________________________________ do hereby consent to undergo a drug/alcohol test. . and/or testing facility. and/or any agents of Mutual Security Credit Union. The results of any such test must be confidential and must not be disclosed by the employer or its employees to any person other than any such employee to whom such disclosure is necessary (Sec. the applicant is informed of Mutual Security Credit Union’s intent to perform a drug/alcohol test.CONSENT TO DRUG/ALCOHOL TESTING AND RELEASE OF RESULTS Connecticut law provides that: No employer may require a prospective employee to submit to a urinalysis drug test as part of the application procedure for employment with such employer unless: (1) the prospective employee is informed in writing at the time of application of the employer’s intent to conduct such a drug test. its doctors. to conduct the test and the testing facility to release the results. Signature:_____________________________________________ Date: ____________________ Thank you for completing an application form and for your interest in employment with Mutual Security Credit Union. and Mutual Security Credit Union and its employees from any liability arising from this testing. and (3) the prospective employee is given a copy of any positive urinalysis drug test result. and authorizes Mutual Security Credit Union. and medical personnel. Mutual Security Credit Union is an Equal Opportunity Employer. as required by Mutual Security Credit Union. 31-51u(a). I authorize the hospital and/or testing agency. I. clinic. By this form. Further. (2) such test is conducted in accordance with the requirements of Sec. Employment will be subject to satisfactory results of background checks and drug/alcohol screening in accordance with state and federal law. 31-51v).

Information appearing on this Authorization will be used exclusively by Mutual Security Credit Union for identification purposes and for the release information which will be considered in determining any suitability for employment. I certify that I have made true. This authorization is valid during the course of my employment to the extent permitted by law. or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment. I agree to provide additional information that may be requested to process my employment application. This report may include character and reputation information obtained through personal interviews. labor and wage records and the Fair Credit Reporting Act. misleading statement. Last Name First Name Current Address Middle Name Dates Lived Here Addresses for the Past Seven Years: (include street. education. zip code) Date of Birth Social Security Number Other Names Used (including maiden name) Driver's License # Dates of Residence: Years Used State do hereby authorize verification of all information in my employment application from all sources of employment. and MINNESOTA RESIDENTS ONLY: If you are a current California. Printed Name ________________________________________ Applicant Signature _______________ Date  CALIFORNIA. or any part thereof. correct.AUTHORIZATION TO RELEASE INFORMATION I. criminal history.) I have the right to make a request to Mutual Security Credit Union. and complete answers and statements on my employment application. any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application for employment. Oklahoma. false statement. to request the nature and substance of all information in its files on me at the time of my request. or Minnesota resident and would like to request a copy of your Consumer Report or Investigative Consumer Report. etc. credit and worker's compensation records in accordance with ADA. upon proper identification. and including those which may be deemed to be privileged or confidential in nature and I release all persons from liability on account of such disclosures. including sources of information. . city. financial history. I authorize without reservation. please check the box. personal character. OKLAHOMA. and the recipients of any reports on me which Mutual Security Credit Union has previously furnished within the two year period preceding my request. any party or agency contacted by Mutual Security Credit Union to furnish the above-mentioned information. I understand and agree that any omission. whether the said records are public or private. **I hereby do _______do not_________ authorize you to contact my current employer for Employment and Reference Verifications (This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application. motor vehicle. state. and authorize any duly authorized agent of Mutual Security Credit Union to obtain.

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