Employment Application

General Information and Desired Position

* = Required field

First Name*

Middle Name

Last Name*

Street Address*

Phone*

City*

State*

Zip Code*

Email*

Position(s) applied for*

Type of work desiredFull-TimePart-TimeTemporary

Salary requirement*

Date available for work*

How were you referred to us?*

Are you legally permitted to work in the United States?*

Yes, I am legally allowed to work in the United States. No, I am not legally allowed to work in the United States.

Are you able to provide documentation demonstrating your legal right to work in the United States?*

Yes, I am able to provide documentation demonstrating your legal right to work in the United States. No, I am not able to provide documentation demonstrating your legal right to work in the United States.

Have you been employed by the Bank previously?*

Yes, I have been employed by the Bank previously. No, I have not been employed by the Bank previously.

Have you applied for a position at the Bank before?*

Yes, I have applied for a position at the Bank before. No, I have not applied for a position at the Bank before.

Do you currently have a relative employed by the Bank?*

Yes, I have a relative employed by the Bank. No, I do not have a relative employed by the Bank.

If yes, name and relationship

Use the space below to describe your interest in banking and the skills and aptitudes that you feel qualify you for a position at the Bank.*

Criminal Record

An applicant for employment with a sealed record on file with the Commissioner of Probation may answer "no record" with respect to any inquiry relative to prior arrests, criminal court appearances or convictions.

An applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services provided it did not result in a complaint transferred to the Superior Court for criminal prosecution.

A conviction record is not an automatic bar to employment, except as provided by Section 19 of the Federal Deposit Insurance Act ("FDIA"). Where employment is not barred by Section 19 of the FDIA, factors such as age at time of the offense, time that has passed since the offense or completion of any sentence, seriousness and nature of the offense, rehabilitation and the nature of the job sought will be taken into account.

Have you ever been convicted of a felony?*

Yes, I have been convicted of a felony. No, I have not been convicted of a felony.

If yes, please identify any and all felonies and explain

Have you been convicted of a misdemeanor within the past five years or finished a period of incarceration for a misdemeanor within the past five years?*

Yes, I have been convicted of a misdemeanor within the last five years or finished a period of incarceration for a misdemeanor within the past five years. No, I have not been convicted of a misdemeanor within the last five years or finished a period of incarceration for a misdemeanor within the past five years.

You need not answer "Yes" with respect to a first conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace.

If yes, please identify any and all misdemeanors (except those excluded above) and explain

Education

High School/Prep

Name

City/State

Major Course / Subject

Last Year Completed

Degree

Business School

Name

City/State

Major Course / Subject

Last Year Completed

Degree

College

Name

City/State

Major Course / Subject

Last Year Completed

Degree

Graduate Work

Name

City/State

Major Course / Subject

Last Year Completed

Degree

List scholastic honors, offices held and activities in high school and college

If you did not graduate, why did you leave school or college?

Are you planning to pursue further studies?*

Yes, I plan to continue my education. No, I do not plan to continue my education.

If yes, where and what courses?

Employment Record

Please list the most recent information first. Account for all periods of time and all positions held over the last 10 years, including military service. You may include volunteer positions if you wish. Please indicate if additional space is needed.

First Employer

Start Date

End Date

Street Address

City/State

Zip Code

Reference

Reference Phone

Position and Duties

Reason for Leaving

Second Employer

Start Date

End Date

Street Address

City/State

Zip Code

Reference

Reference Phone

Position and Duties

Reason for Leaving

Third Employer

Start Date

End Date

Street Address

City/State

Zip Code

Reference

Reference Phone

Position and Duties

Reason for Leaving

Have you ever been involuntarily terminated from employment in any job, including but not limited to any of the positions identified in this application or your resume?*

Yes, you may contact my current employer. No, I have not been involuntarily terminated before.

If yes, please explain any and all such circumstances

If presently employed, why do you desire to change your position?

If you are presently employed, may we contact your current employer?*

Yes, you may contact my current employer. No, you may not contact my current employer.

Disclosures

The Bank is an equal employment opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex, gender identity, sexual orientation, genetic information, ancestry, age, disability, military or veteran status or any other category protected by federal or state law. No question on this application is intended to secure information to be used for such discrimination.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

This application will be given consideration, but its receipt does not imply that you will be employed. The Bank, at its own expense, arranges for a bond for each of its employees. If your (the applicant's) background is unacceptable to a bonding company (under standards that do not discriminate on an illegal basis), it will be difficult to secure this bond, and the Bank may not offer employment to you.

Please read carefully before signing. If you have any questions regarding this statement, please ask them of an employment interviewer before signing.

Affidavit

I authorize the Bank to make inquiries regarding my work and educational history from any of my past employers and from educational institutions that I have attended. I release the Bank, as well as my past employers and educational institutions, from any and all liability or damage for requesting and/or issuing this information.

I acknowledge receipt of a separate statement that the Bank may obtain a consumer report on me for purposes of this employment application and, should I become employed by the Bank, at any time during my employment with the Bank.

I understand that if I am hired, I must provide proof of eligibility to work in the United States. If I do not provide such proof within three (3) days of my hire, I understand that the Bank may terminate my employment.

I understand that, if I am hired, my employment with the Bank will be at will and may be terminated by the Bank or me at any time and for any reason. I understand that no documents or statements of the Bank will constitute a contract of employment that in any way limits the Bank's right to terminate employment at will. I further understand that the at-will nature of my employment cannot be changed except by a formal written contract signed by both the President of the Bank and me.

Without limiting in any way the at-will status of my employment if I am hired, I understand that if any of the information I have provided on this application or any accompanying resume is untrue, the Bank will immediately discharge me.

I hereby acknowledge that I have read the above statement and understand the same.

Signature*

Date*

Voluntary Self Identification Form – Race/Sex

As a Government Contractor, subject to Executive Order 11246, Section 503 of the Rehabilitation Act of 1973 and the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, Bluestone Bank ("Employer") takes affirmative action to actively recruit, employ and advance in employment qualified minorities, females, qualified disabled individuals, Armed Forces service medal veterans, recently separated veterans, qualified disabled veterans and other protected veterans.

The information on this form helps us comply with Federal and State Equal Employment Opportunity requirements and our Affirmative Action Program. Note that the completion of this form is voluntary on your part. If you already work for Bluestone Bank, your answers will not be used against you in any way. If you are an applicant, completed forms will be maintained in a file separate from employment applications and will not be used to discriminate against or show preference for any applicant. Employer will keep such information confidential, except that government officials investigating Employer for affirmative action compliance may be informed.

If you choose to provide us with this information, you may do so at this time or at any time in the future.

Signature*

Date*

Sex

Male Female

Please specify your Race/Ethnic classification by first indicating whether you consider yourself to be.

Hispanic or Latino

Yes, I am Hispanic or Latino. No, I am not Hispanic or Latino.

If you are not Hispanic or Latino, please check one or more of the following racial categoriesAmerican Indian/Alaskan Native (Not Hispanic or Latino)Black or African American (Not Hispanic or Latino)White (Not Hispanic or Latino)Asian (Not Hispanic or Latino)Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)Two or more races (Not Hispanic or Latino)

For information regarding the definitions of the foregoing racial/ethnicity categories, please see the Race/Ethnic Identification Table below or contact Employer's Human Resources Department at hr at bridgewatersavings dot com.

Race/Ethnic Identification

Race/Ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. For the purposes of record-keeping, an employee maybe included in the group to which she/he appears to as belonging.

The following **race/ethnic groups** are recognized by the EEOC for reporting purposes:
Hispanic or Latino	All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Asian	(Not Hispanic or Latino) — All persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This area includes for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
White	(Not Hispanic or Latino) — All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black or African American	(Not Hispanic or Latino) — All persons having origins in any of the Black racial groups of Africa.
Native Hawaiian or Other Pacific Islander	(Not Hispanic or Latino) — All persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaskan Native	(Not Hispanic or Latino) — All persons having origins in any of the original peoples of North and South America (including Central America) and who maintain cultural identification through tribal affiliation or community recognition.
Two or More Races	(Not Hispanic or Latino) — All persons who identify with more than one of the above five races.

Voluntary Self Identification Form – Veterans

1. Bluestone Bank is 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:

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.

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.

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.

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.

2. 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 are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified "protected veteran" category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.

I belong to the following classifications of protected veterans (choose all that apply)Disabled VeteranRecently Separated VeteranActive Wartime or Campaign Badge VeteranArmed Forces Service Medal Veteran-------------------------------------------I am a protected veteran, but I choose not to self-identify the classifications to which I belongI am not a protected Veteran

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

3. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. If you already work for Bluestone Bank, your answers will not be used against you in any way. If you are an applicant, completed forms will be maintained in a file separate from employment applications and will not be used to discriminate against or show preference for any applicant. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.

4. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

5. If you wish to review Employer's Affirmative Action Plan for Disabled Individuals, Armed Forces Service Medal Veterans, Recently Separated Veterans, Disabled Veterans and Other Qualified Veterans, please contact Employer's Human Resources Department at hr at bridgewatersavings dot com.

Disclosures

Please understand that in connection with your application for employment at Bluestone Bank a consumer report for employment purposes including, but not limited to; credit cards, criminal background checks, employment and educational references will be obtained on you. Further, should you become employed here, a consumer report for employment purposes including, but not limited to; credit cards, criminal background checks, employment and educational references may be obtained on you at any time during your employment at Bluestone Bank.

By signing the below acknowledgment and authorization, you are hereby authorizing Bluestone Bank to procure a consumer report for employment purposes including, but not limited to; credit records, criminal background checks, employment and educational references on you at any time during your employment at Bluestone Bank.

Sincerely,
Carol A. DeMoranville
SVP & Human Resource Officer

Please read the following information as part of the online application process.

I have read and understand the Disclosure regarding background investigation* I have read and understand the Summary of Your Rights Under the Fair Credit Reporting Act*