APPLICATION FOR EMPLOYMENT

PRINT IN BLACK INK OR TYPE. These instructions must be followed exactly. Fill out application form completely.
If questions are not applicable, enter “NA”. Do not leave questions blank. Be sure to sign when completed. Promontory Interfinancial Network, LLC is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. You may make copies of this application and enter different position titles, but each copy must have an original signature. Resumes will not be accepted in lieu of applications.. Applications containing unsolicited personal data will be rejected. This application becomes the property of Promontory Interfinancial Network, LLC.

NAME ______

MAILING ADDRESS (Current) AC ______

(Street) (City) (State) (Zip) (Daytime Phone)

List any other names used if different from name given on this application.

Month and Year of Birth: ______

LIST EXACT TITLE OF POSITION OR TYPE OF WORK FOR WHICH YOU WISH TO APPLY:
/ SALARY REQUIREMENTS:
IF REFERRED BY A CURRENT PROMONTORY INTERFINANCIAL NETWORK, LLC EMPLOYEE, PLEASE PROVIDE NAME:

Full-Time Part-Time Summer Temp/Project Date available for work

Are you willing to travel? Yes No If yes, what percent of time?

Are you at least 17 years of age? Yes No

Have you ever been convicted of a felony? Yes No If your answer is “Yes,” explain in concise detail on a separate sheet of paper, giving the dates and nature of the offense, the name and location of the court, and the disposition of the case. A conviction may not disqualify you, but a false statement will.

EDUCATION (NOTE: Applicants may be required to provide proof of diploma, degree, transcripts, licenses, certifications and registrations.)

Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 Did you graduate/achieve GED? Yes No

Type of / Dates Attended / Sem./Clock / Graduated / Expected / Type of / Major/Minor
School / Name and Location of School / From / To / Hours / Graduation / Diploma or / Field of
Mo. / Yr. / Mo. / Yr. / Completed / Yes / No / Date / Degree / Study
Undergraduate
Colleges or
Universities
Graduate
Schools
Technical,
Vocational, or
Business
Schools


If a license, certificate, or other authorization is required or related to the position for which you are applying, complete the following:

LICENSE/CERTIFICATION (include securities licenses) / Date Issued / Issued by / License No. / Location of Issuing Authority (city & state)

Special Skills/Qualifications: List all special skills you possess and machines or office equipment you can use, such as calculators, printing

or graphics equipment, computer equipment, types of software and hardware, etc.

Approximate Words Per Minute in Typing (if required for this position)

Do you speak a language other than English? (If required for this position) Yes No

If yes, what language(s) do you speak? How fluently? Fair Good Excellent

Do you have any relatives working for this company? Yes No If yes, list the names and relationships.


EMPLOYMENT HISTORY

This information will be the official record of your employment history and must accurately reflect all significant duties performed. Summaries of experiences should clearly describe your qualifications.

1.  Resumes cannot be substituted for completing this employment application.

2. Include ALL employment for the past 10 years. Begin with your current or last position and work back to your first position.

3. Employment history should include each position held, even those with the same employer.

4. Break out annual base salary and annual bonus/commission

5. Give a brief summary of the technical and, if appropriate, the managerial responsibilities of each position you have held.

6. For supervisory/managerial positions, indicate the number of employees you supervised.

If you need additional space to adequately describe your employment history, you may use this employment history sheet or attach a typed employment history providing the same information in the same format as this application form.

Name

Last Name First Name Middle Name Social Security No.

Position Title: / Immediate Supervisor / Full- Time
Employer: / Name / Part-Time
Mailing Address: / Summer
City and State/Zip: / Title / Temp/Project
Employer’s Telephone No: AC ( ) / Supervisor’s Telephone No. / Give average
Starting Date Leaving Date / Base Salary / Technical / AC ( ) / number of hours
Mo. / Day / Yr. / Mo. / Day / Yr. / (Bonus) / Non-managerial / If supervisory, / worked per week
Supervisory/Managerial / number of employees you supervised / if part-time
Summary of experience:
Specific reason for leaving:
Position Title: / Immediate Supervisor / Full- Time
Employer: / Name / Part-Time
Mailing Address: / Summer
City and State/Zip: / Title / Temp/Project
Employer’s Telephone No: AC ( ) / Supervisor’s Telephone No. / Give average
Starting Date Leaving Date / Base Salary / Technical / AC ( ) / number of hours
Mo. / Day / Yr. / Mo. / Day / Yr. / (Bonus) / Non-managerial / If supervisory, / worked per week
Supervisory/Managerial / number of employees you supervised / if part-time
Summary of experience:
Specific reason for leaving:
Position Title: / Immediate Supervisor / Full- Time
Employer: / Name / Part-Time
Mailing Address: / Summer
City and State/Zip: / Title / Temp/Project
Employer’s Telephone No: AC ( ) / Supervisor’s Telephone No. / Give average
Starting Date Leaving Date / Base Salary / Technical / AC ( ) / number of hours
Mo. / Day / Yr. / Mo. / Day / Yr. / (Bonus) / Non-managerial / If supervisory, / worked per week
Supervisory/Managerial / number of employees you supervised / if part-time
Summary of experience:
Specific reason for leaving:
Position Title: / Immediate Supervisor / Full- Time
Employer: / Name / Part-Time
Mailing Address: / Summer
City and State/Zip: / Title / Temp/Project
Employer’s Telephone No: AC ( ) / Supervisor’s Telephone No. / Give average
Starting Date Leaving Date / Base Salary / Technical / AC ( ) / number of hours
Mo. / Day / Yr. / Mo. / Day / Yr. / Bonus / Non-managerial / If supervisory, / worked per week
Supervisory/Managerial / number of employees you supervised / if part-time
Summary of experience:
Specific reason for leaving:
Position Title: / Immediate Supervisor / Full- Time
Employer: / Name / Part-Time
Mailing Address: / Summer
City and State/Zip: / Title / Temp/Project
Employer’s Telephone No: AC ( ) / Supervisor’s Telephone No. / Give average
Starting Date Leaving Date / Base Salary / Technical / AC ( ) / number of hours
Mo. / Day / Yr. / Mo. / Day / Yr. / (Bonus) / Non-managerial / If supervisory, / worked per week
Supervisory/Managerial / number of employees you supervised / if part-time
Summary of experience:
Specific reason for leaving:

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING

AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED

1. I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, or omission of information shall be grounds for refusal to hire or, if hired, termination.

2. I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S.

3. I understand that nothing on this application is intended to create or imply a contractual relationship; if hired, I understand that employment is at will, i.e., that it is not for any specific time period or duration, and can be terminated with or without reason at any time. While employment policies or procedures may change from time to time, only a written agreement signed by the a company officer can change the employee’s at-will status.

4. I authorize any of the persons or organizations referenced in this application and outside background investigation agencies to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you.

5. By signing below, you attest to the accuracy of the information you provided on this employment application.

SIGN

THIS APPLICATION MUST BE SIGNED HERE:

Signature-Applicant Date

EEO Applicant Data

Completion of this form is voluntary. The data on this form will not be used to make hiring decisions or any other types of decisions affecting your eligibility for employment. The data requested on this form will be used solely for reporting to the Federal or State agencies. This completed form will be separated from the application form.

Applicant’s Name: ______

Please check the categories that apply to you:

Race

American Indian

Asian/Pacific Islander

Black

Hispanic

White

Other: ______

Gender

Female

Male

Age

Over 39 Yes No

Veteran Status

Vietnam-era Vet Yes No

Definition:

a)  a person who served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred: (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975 or (ii) between August 5, 1964 and May 7, 1975, in all other cases; or

b)  a person who was discharged or released from active duty for a service-connected disability if any part of such active duty was performed (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964, and May 7, 1975 in all other cases

Special Disabled Vet Yes No

Definition:

a)  A veteran 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 Department of Veterans’ Affairs for a disability (i) rated at 30% or more, or (ii) rated at 10 or 20% in the case of a veteran who has been determined under Section 1506 of Title 38, U.S.C. to have a serious employment handicap or

b)  Person who was discharged or released from active duty because of a service –connected disability.

Other Veterans Yes No

Definition: veterans who served on active duty during a war or in a campaign or expedition for which a campaign budget has been authorized. To identify the campaign or expeditions that meet this criterion, access http://www.opm.gov/veterans/html/vgmedal2.htm.