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Application For Employment - Return to Client Forms

 

Application Date:  

Position Applying for:  
Date Available:  

Contact Information

    
First Name:  
Last Name:  
Middle Name:  
Address 1:  
Address 2:  
City:  
State:  
Zip Code:  
Home Phone:  
Cell Phone:  
     
Social Security Number:  
Do you have Transportation?:   Yes No
Drivers License #:  
State:  
Any accidents or violations in the past three years?   Yes  No
If yes, please explain:  
     
Hours available to work:  
     
Are you at least 18 years old?   Yes No
Have you ever been convicted of a felony:   Yes No
If yes, please explain:  
     
Are you prohibited from lawfully becoming employed in this country because of visa or immigration status:   No Yes
     
Typing WPM:  
10 Key Experience:   Yes No
     
Software programs you are experienced with:  
     
Do you have your Nevada Property & Casualty Insurance License?   Yes No
Do you have any insurance designations:   Yes No
If yes, please list:  
     
Have you ever been in the Armed Forces:   Yes No
If yes, please explain:    
Are you a member of the National Guard?   Yes No
     

Education:
School Type School Name Address Years Completed Major/Degree
High School
College
Business or Trade School
Other
 
Work History:
Please list your work experience for the past ten (1) years beginning with your most recent job.
Name of Employer Name of Supervisor Employment Dates Start/Final Pay or Salary

Reason for Leaving: (please be specific)
 
Name of Employer Name of Supervisor Employment Dates Start/Final Pay or Salary

Reason for Leaving: (please be specific)
 
Name of Employer Name of Supervisor Employment Dates Start/Final Pay or Salary

Reason for Leaving: (please be specific)
 
Name of Employer Name of Supervisor Employment Dates Start/Final Pay or Salary

Reason for Leaving: (please be specific)
 
Name of Employer Name of Supervisor Employment Dates Start/Final Pay or Salary

Reason for Leaving: (please be specific)
 
May we contact your current employer: Yes  No
 
Personal References:
Please list references other than relatives or previous employers.
Name Company Position Address Phone Fax or Email
 
Other Interests:
 
Certification:
I certify that the information provided is true and complete, to the best of my knowledge. I realize that any misrepresentations in the information so provided (whether intentional or un-intentional) may result, if hired, in my immediate dismissal. I authorize the above company to check all references from current and previous employers and any person listed as a reference on this application that may be relevant to my employment or my ability to perform the job for which I applied.

I authorize the company to verify any of the information furnished in this application including, but not limited to, criminal history and driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background that may be relevant to evaluation of this application and I hereby release any such persons, schools, companies and law enforcement authorities from any liability for damages whatsoever for issuing this information to this company and/or its agents.

I hereby acknowledge and agree that if employed by company, such employment relationship is at-will; that is, I would be free to resign from the company whenever I wish, and the Company is not restricted from terminating any employee at any time for any or no reason.

I further understand that my employment with the company would not be for any specific fixed period or term. At no time shall any oral statement by the management of the company be construed as giving rise to or creating a contract of employment between the Company and me or any other employee, or otherwise alter or modify the at-will nature of the employment relationship.

I understand that the company prohibits the use and possession of controlled substances and/or alcohol on its premises. As required by the company’s policies, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
 
Applicant Signature:

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