Ruby Award Questionnaire Form 1st State Bank

Ruby Award Questionnaire

Name(Required)

First Last

Date of Birth(Required)

Home Address

Street Address Address Line 2 City State ZIP Code

Work Address

Street Address Address Line 2 City State ZIP Code

Job Title(Required)

Company Name(Required)

Hire Date(Required)

Please answer only one of the following two questions(Required)

Option 1: What has been your work history with the current employer?

Option 2: As a business owner/ entrepreneur, detail the origins of your business. Describe your experience developing your business into its current form.

Answer:(Required)

What is your educational background?(Required)

Are you a member of any trade organization in your industry? Do you hold (or have held) any position(s) with these organizations?(Required)

What do you consider to be your greatest professional accomplishment in your field? When was this achieved in relationship to when you began employment in your field?(Required)

Have you received recognition within your profession for your past accomplishments? If so, when, and how were you recognized?(Required)

What makes you stand out in your field?(Required)

What type of growth, achievements, recognition, change, or major company milestones has your company accomplished/received during your tenure? What has been your influence in those accomplishments or changes?(Required)

Statement of Release

I CONSENT AND AUTHORIZE 1ST STATE BANK ACTING THROUGH ITS AGENTS, EMPLOYEES, OR REPRESENTATIVES, TO TAKE PHOTOGRAPHS, VIDEO RECORDINGS, AND/OR AUDIO RECORDINGS OF ME, INCLUDING MY NAME, MY IMAGE, MY LIKENESS, AND/OR MY VOICE (“RECORDINGS”) FOR PURPOSES OF PROMOTION OF 1ST STATE BANK’S RUBY AWARD. I ALSO GRANT 1ST STATE BANK THE RIGHT TO REPRODUCE, USE, EXHIBIT, DISPLAY, BROADCAST, CREATE DERIVATIVE WORKS FROM, AND DISTRIBUTE THE RECORDINGS IN ANY MEDIA NOW EXISTING OR HEREAFTER DEVELOPED, IN PERPETUITY. I AGREE THAT THE RECORDINGS MAY BE USED BY 1ST STATE BANK FOR ANY LAWFUL PURPOSE RELATED TO THE RUBY AWARD, INCLUDING BUT NOT LIMITED TO, MARKETING, ADVERTISING, PUBLICITY, OR OTHER PROMOTIONAL PURPOSES. I ACKNOWLEDGE THAT I AM NOT EXPECTING TO RECEIVE COMPENSATION FOR PARTICIPATING IN THE RECORDINGS OR FOR ANY FUTURE USE OF THE RECORDINGS.

Release Authorization(Required)

I grant permission

1st State Bank will be closed Friday, July 3rd and Saturday, July 4th in observance of Independence Day

1st State Bank will be closed Friday, June 19th in observance of Juneteenth