Notice to Applicant: We appreciate your interest in Cornerstone Bank. To be considered for the following position the application must be filled out completely.

Position Applying for: Part-time Teller - Fargo

Applicant Name :  
Telephone:Email Address:
AddressCity State
Are you 18 years old or older?

Are you either a U.S. citizen or an alien authorized to work in the U.S.?
Have you ever worked or attended school under another name? If so, under what name?
Have you ever been convicted, pled guilty or no contest to a crime other than a minor traffic conviction (for example, speeding tickets)?* 
If yes, give details, including date(s):
* A “yes” answer will not automatically disqualify you from employment.  We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.
Position Desired
Position Location:
Date you can start:
Hourly rate / monthly salary desired:
Do you prefer:
If part-time, hours per week desired:
Hours you are available to work:
Days of the week you are available to work:
Are you able to work:
* if required for the position for which you’re applying
Are you available to work overtime?
Have you previously worked for this company?
If so from to
Reason for leaving:
Former supervisor(s) at this company:
How did you learn about this opening?
Have you ever been terminated from employment or asked to resign in lieu of termination?
If so, explain:
Attach Resume:
Additional File:
High School:GraduatedCourse of Study:
Technical School:GraduatedCourse of Study:
College / University:GraduatedCourse of Study:
Other education or training:
Other special skills:
Work Experience
From to
Position Held:
Reason for Leaving
Supervisors Name Title Telephone  
May we contact?
Description of Duties:
Starting Hourly Pay: Final Hourly Pay:  
From to
Position Held:
Reason for Leaving
Supervisors Name Title Telephone  
May we contact?
Description of Duties:
Starting Hourly Pay: Final Hourly Pay:  
From to
Position Held:
Reason for Leaving
Supervisors Name Title Telephone  
May we contact?
Description of Duties:
Starting Hourly Pay: Final Hourly Pay:  
Give names, addresses and phone numbers of at least three people who are not related to you and who have known you for at least 1 year.  Please indicate how you know each reference and how long you have been acquainted.  Former employers, coworkers or educators are preferred.  Complete all information necessary for us to contact each reference by phone and/or mail.
 NameAddressPhoneHow do you know this referenceNumber of years acquainted
Authorization and Acknowledgments
I certify that the facts contained in this application are true and complete to the best of my knowledge.  I understand that if I am employed, any false statements or omissions on this application or any other materials I have submitted in support of my application may be grounds for dismissal.

I authorize investigation of all statements contained in this application.  I also grant permission to contact all references listed above, and authorize them to release all information concerning my previous employment and any other pertinent information these references might have, personal or otherwise.  I release all parties from all liability for any damage that may result from furnishing this information to you.  I agree that any offer of employment is contingent on successful completion of a background investigation by the Bank.

I understand and agree that, if hired, my employment is “at will.”  I understand that either I or Cornerstone Bank are free to terminate the employment relationship at any time for any lawful reason with or without prior notice.
Applicant Name:

The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. This form will be used for statistical reporting purposes only and will be kept separate from all other personnel records.

Name:Position Applying For:
Voluntary Self Disclosure
GENDER: (Please check one of the options below)


Date Completed:

We are a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

  1. 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 service-connected disability.
  2. 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.
  3. 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.
  4. 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.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Voluntary Self-Disclosure
Name: Date:

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.

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
  • Multiple sclerosis (MS)
  • Impairments requiring the use of a wheelchair
  • Diabetes
  • Schizophrenia
  • Missing limbs or partially missing limbs
  • Intellectual disability (previously called mental retardation)
  • Epilepsy
  • Muscular dystrophy

Please check one of the boxes below:

Voluntary Self-Disclosure

Name: Date:

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.