Application for Employment

AN EQUAL OPPORTUNITY EMPLOYER          Date*:
* = required field

Personal Information

First Name*:
Last Name*:
Middle Name:
E-mail:*
Present Address*:
City*:
State*:
ZIP*:
Phone*:

Employment

Position:
Date you can start:
Salary Desired:
Are you employed now?:
If so may we inquire of your present employer?:
Referred by:
A previous applicant?: Yes No    When
A previous employee?: Yes No    When
Are you legally authorized to work in the United States?: Yes No
Proof of citizenship or immigration status will be required upon employment.
Have you ever been convicted of a crime?: Yes No   
If Yes, please explain:

A criminal record is not an automatic bar to employment. This information will be considered only as it relates to the job. Applicants are not obligated to disclose sealed or expunged conviction records.

Education and Training

High School
Name and location:
# of years attended:
Diploma/Degree?:
Course of study:
 
College
Name and location:
# of years attended:
Diploma/Degree?:
Course of study:
 
Other
Name and location:
# of years attended:
Diploma/Degree?:
Course of study:
Do you have insurance training or experience in insurance agency or company?: Yes No
Please explain:
Have you used insurance software?: Yes No
If so, please list:
Computer skills:
Specialized training licenses or skills acquired:

Employment History

Company 1
Name/address phone:
Employment dates: From: To:
Positions held
Job duties:
Salary:
 
Company 2
Name/address phone:
Employment dates: From: To:
Positions held
Job duties:
Salary:
 
Company 3
Name/address phone:
Employment dates: From: To:
Positions held
Job duties:
Salary:
 
Which of these jobs did you like best and why?:

References

Give names of 3 persons not related to you, whom you have known at least one year.

Person 1
Name:
Address:
Business:
Phone:
Years acquainted:
 
Person 2
Name:
Address:
Business:
Phone:
Years acquainted:
 
Person 3
Name:
Address:
Business:
Phone:
Years acquainted:
 
I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND AND AGREE THAT ANY MISREPRESENTATION, FALSIFIED STATEMENTS OR OMISSION BY ME IN THIS APPLICATION WILL BE SUFFICIENT REASON FOR REFUSAL OF EMPLOYMENT OR FOR DISMISSAL AT ANY TIME DURING MY EMPLOYMENT, WITHOUT LIABILITY TO THIS COMPANY.
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.
I UNDERSTAND AND AGREE THAT IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.
I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT.
I UNDERSTAND THIS APPLICATION WILL BE ACTIVE FOR A PERIOD OF 60 DAYS; AFTER THAT TIME, IF I WISH TO BE CONSIDERED FOR EMPLOYMENT I MUST SUBMIT A NEW APPLICATION.

This form has been designed to comply with State and Federal fair employment practice laws prohibiting employment discrimination.


I have read and agree with the above statement.