Application for Employment

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp

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:

• Autism
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
• Blind or low vision
• Cancer
• Cardiovascular or heart disease
• Celiac disease
• Cerebral palsy
• Deaf or hard of hearing
• Depression or anxiety
• Diabetes
• Epilepsy
• Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
• Intellectual disability
• Missing limbs or partially missing limbs
• Nervous system condition, for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS)
• Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Reasonable Accommodation Notice

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.

Please read carefully before agreeing.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for The Farmers Bank to hire me. If I am hired, I understand that either The Farmers Bank or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of The Farmers Bank has the authority to make any assurance to the contrary.

I attest with my agreement below that I have given to The Farmers Bank true and complete information on this application. No requested information has been concealed. I authorize The Farmers Bank to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.