Insurance Clerk

First name*

Last name*

Email address*

Location

Phone number*

Resume*

Name*

Phone Number*

Present Address*

If at present address less than one year, please provide previous address

Social Security Number

Contact in Case of Emergency

Are you at least 18 years old? (Employment is subject to verification of minimum legal age)*

Can you produce documented proof of your identity and eligibility for employment in the United States? (Examples: driver's license, social security card, birth certificate, and/or immigration and naturalization service documents)*

Positions applied for

How soon can you report to work?

Type of employment desired?

Have you worked for us before?*

If part time, what days/hours?

Rate of pay expected*

Do you possess a high school diploma or equivalent?*

Highest level of education completed (Information will be used only to the extent relevant to the qualifications and position for which you apply)*

Have you applied for a job with us before?*

How did you come to apply?

Have you ever been bonded?*

Have you ever refused a bond?

If yes, state reason and date

Have you ever been discharged or requested to resign from a position?

Are you employed now?

If yes, may we contact current employer?

Have you ever held a position of trust (handling money or confidential material)?

If yes, describe

Do you have a reason to believe that you would have difficulty meeting this company's work schedule?*

Have you ever been convicted of, pled guilty or "no contest" (nolo contendere) to, a misdemeanor or felony? Do not include minor traffic infractions for which you never appeared in court, offenses which were dismissed or discharged after completion of successful probation, and convictions or pleas which have been deemed sealed, annulled, or expunged by law.

NOTE: Answering "Yes" to This question is not an automatic bar to employment. Factors such as age at the time of the offense, seriousness, and nature of the violation, relatedness to the job sought, amount of time which has passed since the event occurred, and evidence of rehabilitation will be taken into account. However, please be advised that a misstatement or omission in answering this question may be grounds for disciplinary action including discharge.*

If yes, give details concerning the type of crime, the date of the conviction or plea, the penalty imposed, and any other circumstances you deem relevant to a full understanding of what occurred. Use additional sheets if necessary.

Have you ever been arrested or charged with any misdemeanor or felony not disclosed above for which you are out on bail or free on your own recognizance pending disposition or trial (again, do not include minor infractions for which no court appearance is necessary)?*

If yes,give the date(s) and details of the arrest or charge substantially relavent to the circumstances of the particlar job sought, and other considerations allowed by law. Again, please be advised that a misstatement or omission in answering the question may be grounds for disciplinary action, including discharge.

Have you even been sued in a civil action with regard to the death of or personal injury or intentional damage to any person or to any property?*

If yes, give details concerning the nature of the claims and the defenses raised by the parties, the outcome of the action (e.g. settlement, jury verdict, or other disposition), and any other circumstances you deem relevant to a full understanding of what occurred. Attach additional sheets if necessary.

Are you prevented from lawfully becoming employed in the country because of Visa or Immigration Status?*

Are you currently engaged in using illegal drugs?*

Most recent employment information:
Name and Address
Telephone Number
Immediate Supervisor Name/Position
Date Hired
Date Left
Starting Rate
Last Rate
Your Job Title and Duties
Reason for leaving*

Second most recent employment information:
Name and Address
Telephone Number
Immediate Supervisor Name/Position
Date Hired
Date Left
Starting Rate
Last Rate
Your Job Title and Duties
Reason for leaving*

Third most recent employment information:
Name and Address
Telephone Number
Immediate Supervisor Name/Position
Date Hired
Date Left
Starting Rate
Last Rate
Your Job Title and Duties
Reason for leaving*

May we contact the employers listed above?*

If not, indicate which you do not wish to contact?

List four references with name, address, phone number, and occupation.

The facts set forth above in my application for employment are true and complete. I understand that if employed, false statement or omission of information on this application, a resume, or other applicant information provided may be considered sufficient reason for dismissal. I understand that consumer reports which may contain public record information may be requested from the reporting agency. These reports may include information as to my character, work habits, performance, and experiences along with reasons for termination of past employment from previous employers. Further, I understand that you may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences. I understand that I have the right to make a written request within a

I authorize the use of any information in this application to verify my statements, and I authorize the past employers all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I understand that employment at this organization is on an "at-will" basis, and includes no guarantee, contract, or promise or employment for any specific length of time.

In consideration of an offer of employment, I hereby acknowledge, understand and agree that the following will constitute terms and conditions of any such employment.

Any losses or expenses incurred by my employer, its clientele, or other third parties as a result of my unauthorized actions shall be immediately reimbursed to my employer on terms that are satisfactory and acceptable to my employer. To the extent permitted by law. I agree and hereby authorized my employer to reduce my wages for any sums owing by me hereunder.

Full legal signature and date required*

Human Check*