Employment Application
Content
Application
In order for your credentials to be given full consideration, please use ink and complete this application in its entirety. Please print or type all information requested except signature. Last name __________________________________ First name ________________________ Middle ___________ Social Security #_______________________________ Date ___________________________ Address _______________________________________________________________________________________ Street/Apartment City State Zip Telephone _____________________________ E-mail _____________________________ Position applied for _________________________________________________________
Position desired
■ Full-time ■ Part-time Full or part-time date available for employment ________________________ Salary desired _____________________
Personal information
■ Yes ■ No ■ Yes ■ No ■ Yes ■ No Are you legally eligible to work in this country? (You must be authorized to work in the United States at the time of hire for purposes other than practical training and without employer sponsorship of non-immigrant work visa.) Are you under 18? (Federal or state law limits employment for certain positions for individuals under 18 years of age. In some cases, a work permit is required.) Have you ever pled guilty to or been convicted of any crimal offense other than a minor traffic violation?
(If yes, explain below. Include number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were, sentence imposed and type of rehabilitation. Use additional paper if necessary. You are not obligated to disclose sealed or expunged records of a conviction or arrest….only applies to IL _____________________________________________ _______________________________________________________________________________________________________
■ Yes ■ No
Are you a U.S. veteran? If yes, complete the following: Specialty or training ______________________________Branch of service _____________________ Name of school Number of yrs completed Diploma/ degree Major/minor
Type of school High School Jr. College College/University Other Specialized skills/licenses/certifications
Active state licenses, registrations, designations
■ ■ ■ ■ ■
Personal computer Microsoft Word ■ EXCEL ■ Other ___________ Typing/Keying _______ wpm Calculator Other _____________________________________
■ ■ ■ ■ ■ ■
CIA ■ NASD Series 6 ■ ACS CPA ■ Property & Casualty ■ CCP FLMI ■ Life/Health CLU/ChFC ■ LUTCF CPCU ■ IIA Other _______________________________
Currently appointed with (company(ies): 1. 2. 3.
Current license(s) expiration date:
AM-001431 (6/05)
Page 1 of 3
Work history
Employer Address Phone Responsibilities Reason for leaving Salary May we contact ■ Yes ■ No
Employer Address Phone Responsibilities
Reason for leaving Salary May we contact? ■ Yes ■ No
Employer Address Phone Responsibilities
Reason for leaving Salary May we contact? ■ Yes ■ No
AM-001431 (6/05)
Page 2 of 3
Work history (Cont.)
Employer Address Phone Reason for leaving Salary May we contact ■ Yes ■ No
Responsibilities
________________________________________________________________________________________________
References
List four work/business/school references (not related to you). Include telephone number and/or e-mail address. 1. 2.
3.
4.
I attest that I have completed this application completely and honestly. I understand that references may be contacted and hereby authorize such contact. I further understand that any false information listed on this application subjects me to being denied employment or, if hired, termination.
______________________________________________ Signature of applicant
______________________ Date
AM-001431 (6/05)
Page 3 of 3
In order for your credentials to be given full consideration, please use ink and complete this application in its entirety. Please print or type all information requested except signature. Last name __________________________________ First name ________________________ Middle ___________ Social Security #_______________________________ Date ___________________________ Address _______________________________________________________________________________________ Street/Apartment City State Zip Telephone _____________________________ E-mail _____________________________ Position applied for _________________________________________________________
Position desired
■ Full-time ■ Part-time Full or part-time date available for employment ________________________ Salary desired _____________________
Personal information
■ Yes ■ No ■ Yes ■ No ■ Yes ■ No Are you legally eligible to work in this country? (You must be authorized to work in the United States at the time of hire for purposes other than practical training and without employer sponsorship of non-immigrant work visa.) Are you under 18? (Federal or state law limits employment for certain positions for individuals under 18 years of age. In some cases, a work permit is required.) Have you ever pled guilty to or been convicted of any crimal offense other than a minor traffic violation?
(If yes, explain below. Include number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were, sentence imposed and type of rehabilitation. Use additional paper if necessary. You are not obligated to disclose sealed or expunged records of a conviction or arrest….only applies to IL _____________________________________________ _______________________________________________________________________________________________________
■ Yes ■ No
Are you a U.S. veteran? If yes, complete the following: Specialty or training ______________________________Branch of service _____________________ Name of school Number of yrs completed Diploma/ degree Major/minor
Type of school High School Jr. College College/University Other Specialized skills/licenses/certifications
Active state licenses, registrations, designations
■ ■ ■ ■ ■
Personal computer Microsoft Word ■ EXCEL ■ Other ___________ Typing/Keying _______ wpm Calculator Other _____________________________________
■ ■ ■ ■ ■ ■
CIA ■ NASD Series 6 ■ ACS CPA ■ Property & Casualty ■ CCP FLMI ■ Life/Health CLU/ChFC ■ LUTCF CPCU ■ IIA Other _______________________________
Currently appointed with (company(ies): 1. 2. 3.
Current license(s) expiration date:
AM-001431 (6/05)
Page 1 of 3
Work history
Employer Address Phone Responsibilities Reason for leaving Salary May we contact ■ Yes ■ No
Employer Address Phone Responsibilities
Reason for leaving Salary May we contact? ■ Yes ■ No
Employer Address Phone Responsibilities
Reason for leaving Salary May we contact? ■ Yes ■ No
AM-001431 (6/05)
Page 2 of 3
Work history (Cont.)
Employer Address Phone Reason for leaving Salary May we contact ■ Yes ■ No
Responsibilities
________________________________________________________________________________________________
References
List four work/business/school references (not related to you). Include telephone number and/or e-mail address. 1. 2.
3.
4.
I attest that I have completed this application completely and honestly. I understand that references may be contacted and hereby authorize such contact. I further understand that any false information listed on this application subjects me to being denied employment or, if hired, termination.
______________________________________________ Signature of applicant
______________________ Date
AM-001431 (6/05)
Page 3 of 3
