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If you are under 18, and it is required, can you furnish a work permit?
Have you ever been employed here before?
Are you legally eligible for employment in this country?
Have you been convicted of a crime in the last 7 years?

Conviction will not be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.

How Did You Hear About Us?

I understand that if I am employed, any misrepresentation or material omission by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions, and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons, corporations, or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

Voluntary Self-Identification of Disability 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. 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 • Deafness • Cancer • Diabetes • Epilepsy • Autism • Cerebral palsy • HIV/AIDS • Schizophrenia • Muscular dystrophy • Bipolar Disorder • Major Depression • Multiple Sclerosis (MS) • Missing Limbs/Partially Missing Links • Obsessive Compulsive Disorder • Post-traumatic Stress Disorder (PTSD) • Intellectual Disability (Previously called Mental Retardation) • Impairments Requiring Use of Wheelchair

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.

>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

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.

Invitation To Employees To Self-Identify For Affirmative Action Purposes

1st Community Credit Union prepares affirmative action plans that cover females, minorities, protected veterans, and individuals with disabilities. This survey is meant to help our company fulfill various objectives in these affirmative action plans. PLEASE NOTE: You are not required to complete any part of this form. Submission of this form is voluntary. The decision not to complete this form will not affect any opportunity for employment or any benefits with the company. Any information you provide in this survey will be kept confidential and will not be used in any way that may adversely affect your employment with this company.

Affirmative Action Related Data (please check appropriate boxes)

RACE (If you checked "Not Hispanic" above, please check one or more of the boxes below.)

This employer is subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974 (VEVRAA) as amended by the Jobs for Veterans Act of 2002, which requires government contractors and subcontractors to take affirmative action to employ and advance in employment disabled veterans, recently separated veterans, active duty wartime or campaign badge veterans, and Armed Forces service medal veterans.

As a government contractor subject to VEVRAA, the company is required to submit a report to the U.S. Department of Labor each year identifying the number of our employees who are protected veterans. If you believe you belong to any of the categories of protected veterans listed below, please indicate by checking the appropriate box. Protected Veteran Categories:

Disabled Veteran - A disabled veteran is one of the following: (a) 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 (b) a person who was discharged or released from active duty because of a service connected disability.

Recently Separated Veteran - A recently separated veteran is a 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 is 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. (Note: The term "Active Duty Wartime Veteran" includes, but is not limited to, a veteran who served any time between 8/5/64 and 5/7 /75, any time between 8/2/90 and the present day, as well as during various military conflicts defined as qualifying events by the Department of Defense.)

Armed Forces Service Medal Veteran - An armed forces service medal veteran is 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.

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