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Information Service

Spokane, Washington, United States
August 17, 2018

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[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT] WestStar Bank may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include a criminal records check, information about your character, general reputation, credentials, credit history, personal characteristics, driving record, and/or mode of living, and which can involve personal interviews with sources such as your current and past employers, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by TRUST Screening Systems, 6070 Gateway Blvd East, Suite 208, El Paso, TX 79905 915-***-****. The scope of this notice and authorization is all-encompassing and allows WestStar Bank to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.


I acknowledge receipt of the NOTICE REGARDING BACKGROUND CHECK and certify that I have read and understand it. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university

(public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by TRUST Screening Systems another outside organization acting on behalf of WestStar Bank. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original. ACKNOWLEDGMENT AND AUTHORIZATION


The following is for identification purposes only to perform the background check and will not be used for any other purpose

TO AVOID DELAYS PLEASE WRITE AS LEGIBLY AS POSSIBLE SOCIAL SECURITY NUMBER - - (ex: ***-**-****) Date of Birth (For Background Purposes Only): / / (mm/dd/yyyy) Current Address: City State Zip Other names you have been known by (Previous, AKAs,etc Previous Cities and States lived in during the past 7 years: City State

City State

City State


If you would like to receive a copy of the background report obtained by TRUST Screening Systems (a Securatis, LLC. Company) please indicate by checking here .

For internal office use only. Please indicate the level of background check you would like Securatis to conduct.: Rev 2006

Disclosure to Employment Application Regarding

Procurement of Credit Report

In connection with your application for employment, we may procure, or cause to be procured, a credit report on you as part of the process of considering your candidacy as an employee. In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to your potential employment, we will provide you with a description in writing of your rights under the law. By your signature below, you hereby authorize us to obtain a credit report about you in order to consider you for employment.

Applicant Name:

Applicant Signature:


City, State, and Zip Code:


Rev 2006

Background Check and Drug Screening Release Form

Authorization and General Release:

I (full legal name printed), in connection with application for employment with WestStar Bank, authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies, military services and former employers to release information they may have about me to WestStar Bank or its agents and release them from any liability or responsibility for doing so.

Further, I authorize the procurement of an investigative consumer report and understand that such a report may contain information about my background, character, and personal reputation. I understand that this notice will also apply to any future update reports that may be requested.

I understand that WestStar Bank promotes an alcohol/drug free workplace. I understand it is the practice of the Bank to conduct pre-employment drug testing. As such, by making application for employment I consent to the drug screening as directed by the Bank and I give my permission to have results released to WestStar Bank. I also understand that any offer of employment will be contingent upon successful completion of the credit, background and drug screenings. Applicant Name:

Applicant Signature:


WestStar Bank

Applicant Data Record

Applicants are considered for all positions and employees are treated during employment, without regard to race, color, religion, sex, national origin, citizenship, age, martial status, medical condition, disability, or any other protected category as defined by Federal, State, or Local law. WestStar Bank is subject to Federal regulations requiring reporting of certain information on applicants for employment. To assist in this effort, all applicants are requested to complete this form. Your cooperation is strictly voluntary. This form will be kept separate from your employment application and the information contained will be kept confidential. It will not be available to personnel involved in the hiring process. The information given will be used only for reporting purposes in accordance with Federal laws and regulations. If you do not wish to provide this information, please print your name, the date and indicated such fact in the appropriate space below. Your decision in this regard will not affect your application. Name: Date:

Position applied for:

Affirmative Action Survey

Check One: Male Female

Check One:


Hispanic of Latino

Black or African American (not Hispanic or Latino) Asian (not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) American Indian/Alaskan Native (not Hispanic or Latino) Two or More Races

I do not wish to provide the requested information. 01/01/2013

Para informacion en espanol, visite o escribe a la Consumer Finanical Protection Buereau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment-or to take another adverse action against you-must tell you, and must give you the name, address, and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free, You are entitled to a free file disclosure if: o a person has taken adverse action against you because of information in your credit report; o you are the victim of identity theft and place a fraud alert in your file; o your file contains inaccurate information as a result of fraud; o you are on public assistance;

o you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need-usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to your employer. Written consent is not required in the trucking industry. For more information, go to


• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-***-****.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For more information go to

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact: Type of Business: Contact:

1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.

1.b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau:

a. Bureau of Consumer Financial Protection 1700 G Street N.W., Washington DC 20552

b.Federal Trade Commission: Consumer Response Center- FCRA Washington DC 20580 877-***-****

2. To the extent not included in item 1 above:

a. National Banks, federal savings associations, and federal branches and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act.

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations.

d. Federal Credit Unions

a. Office of the Comptroller of the Currency

Customer Assistance Group

1301 McKinney Street, Suite 3450

Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center

P.O. Box 1200, Minneapolis, MN 55480

c. FDIC Consumer Response Center

1100 Walnut ST, Box #11, Kansas City, MO 64106

d. National Credit Union Administration

Office of Consumer Protection (OCP)

Division of Consumer Compliance and Outreach (DCCO) 1775 Duke St., Alexandria, VA 22314

3. Air carriers

Asst. General Counsel for Aviation Enforcement &


Department of Transportation

400 Seventh Street SW, Washington, DC 20590

4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation

1925 K. Street NW

Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies

Associate Deputy Administrator for Capital Access

United States Small Business Administration

406 Third Street, SW 8TH Floor

Washington, DC 20416

7. Brokers and Dealers

Securities and Exchange Commission

100 F St NE, Washington, DC 20549

8. Federal Land Bank, Federal Land Bank Association, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration

1501 Farm Credit Drive, McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center- FCRA Washington, DC 20580


Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i 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.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. 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:

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)



Your Name Today’s Date

• Blindness • Autism • Bipolar disorder • Post-traumatic stress disorder (PTSD)

• Deafness • Cerebral palsy • Major depression • Obsessive compulsive disorder

• Cancer • HIV/AIDS • Multiple sclerosis (MS) • Impairments requiring the use of a wheelchair

• Diabetes

• Epilepsy

• Schizophrenia

• Muscular


• Missing limbs or

partially missing limbs

• Intellectual disability (previously called mental retardation)

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Page 2 of 2

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. i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at 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.

Pre-Offer Self-Identification Form

For Protected Veterans

This employer 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. Sec. 4212 (VEVERRA), 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:

o 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

o 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 Offer 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.

[ ] I identify as one or more of the classification of protected veteran listed above.

[ ] I am not a protected veteran

[ ] I do not wish to disclose my status

If you are a disabled veteran it would assist us if you tell us whether there are accommodation 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. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are consistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

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. Date Name (Please Print)


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