APPLICATION FOR EMPLOYMENT

FIRST COMMUNITY BANK is an Equal Opportunity Employer, committed to employing individuals without regard to race, age, sex, color, marital status, veteran status, religion, national origin ancestry or handicap.

Name_____________________________ Social Security Number_____________________

Primary Address ______________________________ Home Phone #__________________

Are you currently employed? ____________ If so, may we contact you at work?_________

Work Phone # ______________________ May we contact your present employer? ______

Person to contact _________________________ Phone # ______________________

If we cannot inquire of your present employer, please explain why:

__________________________________________________________________________

What position(s) are you applying for? ___________________ Salary Desired__________

Have you ever applied to or been employed by this company before?_________ Date_______

Do you have any physical or mental impairment or condition that would limit your job performance in the position(s) for which you are applying? _____

If yes, please explain_________________________________________________________________

Are you prevented from becoming lawfully employed in this Country because of VISA or Immigration Status? ____________ Proof of citizenship or immigration status will be required upon employment.

Are you 18 years or older? ___________ If not, can you furnish a work permit?___________

Are you a smoker? ______ Have you been convicted of a crime, other than a minor traffic violation? ____________

If yes, please explain ______________________________________________________(A conviction record will not necessarily be a bar to your employment. Factors such as the age and type of offense, the seriousness and nature of the violation and your rehabilitation will be taken into account.)

Date you can start employment ___________ Are you on layoff subject to recall? ______________

EMPLOYMENT HISTORY

List below your last four employers, beginning with your current or most recent

Employer__________________________________ Dates__________________________

Address________________________________________ Phone______________________

Supervisor _____________________ Position_______________ Ending Salary______________

Responsibilities______________________________________________________________

Reason for leaving___________________________________________________________

___________________________________________________________________________

Employer__________________________________ Dates__________________________

Address________________________________________ Phone______________________

Supervisor _________________________ Position________ Ending Salary______________

Responsibilities______________________________________________________________

Reason for leaving___________________________________________________________

___________________________________________________________________________

Employer__________________________________ Dates__________________________

Address________________________________________ Phone______________________

Supervisor _________________________ Position________ Ending Salary______________

Responsibilities______________________________________________________________

Reason for leaving___________________________________________________________

___________________________________________________________________________

EDUCATION

Location                            Degree                     Major                      GPA

______________________________________________________________

High School

______________________________________________________________

Trade, Business or Technical

______________________________________________________________

College

______________________________________________________________

Other Special Study or Research Work

______________________________________________________________

Special training, or skills (typing, 10 key calculator, etc.)

______________________________________________________________

Please list any pertinent achievements, awards, hobbies or interests

______________________________________________________________

______________________________________________________________

REFERENCES

Give the name of four persons, not related to you, whom you have known for at least one year. (Two of these persons should be familiar with your work history and/or habits)

Address Phone Occupation Years Acquainted

1.___________________________________________________________________________

2.___________________________________________________________________________

3.___________________________________________________________________________

4.___________________________________________________________________________

Please describe your career goals and how First Community Bank fits into this career path:

______________________________________________________________

______________________________________________________________

APPLICANT'S CERTIFICATION AND AGREEMENT

I understand and agree that, if I am employed by First Community Bank, my employment is for no definite period of time, and that my employment and/or compensation can be modified or terminated, with or without cause, and regardless of the date of payment of my wages and salary, and with or without prior notice at any time, at the option of either First Community Bank or myself. I understand that no representative of First Community Bank, other than the President, the Chairman of the Board, or the Board of Directors as a whole, have any authority to enter into any agreement for my employment for any specified period of time or to make any agreement with me contrary to the foregoing, except that the above mentioned officials of the Company may do so in writing.

I authorize investigation of all information I have disclosed herein so that you may be provided with relevant information concerning my previous educational and employment background. I release all parties from all liability for any damage that my result from furnishing this information of you. This release extends to all pertinent information, personal or otherwise.

I further agree to take any lawful medical examination required by the Company as a condition of my being hired, or, if I am hired, as a condition of my continued employment. I agree that my refusal to take any such lawful examination may be cause for my not being hired, or if I am hired, may be cause for the termination of my employment. I hereby release all persons or companies conducting such examinations for any liability.

Upon signing this document, I, hereby give First Community Bank authority to inquire into my credit records. I am aware that the information received by First Community Bank will only be utilized for employment qualification, and said information will not be utilized for any purpose outside of an employment decision. This release extends to all pertinent information, personal or otherwise.

I certify that the facts contained in this Application are true and complete to the best of my knowledge and understand that if I am employed, any statements I have falsified on this Application shall be grounds for dismissal.

Applicant's Signature__________________________________ Date______________

Interview Comments_____________________________________________

______________________________________________________________

______________________________________________________________

Hired_______________________ Full or Part_______________________

Position____________________________________ Salary/Wage________________

Date reporting for work________________ Approved_________________________

CREDIT BUREAU INQUIRY DISCLOSURE

Upon signing this document, I hereby give First Community Bank authority to inquire into my credit records. I am aware that the information received by First Community Bank will only be utilized for employment qualification and said information will not be utilized for any purpose outside of an employment decision. This release extends to all pertinent information, personal or otherwise.

__________________________________________
First Community Bank Representative