Secure Employment Application

Your Name:

First	Last

Email Address:

Phone Number:

5 Digit Zip:

General Partners Insurance Agency, LLC Employment Application

First Name:

Middle Initial:

Last Name:

Maiden / Former Names:

Address

Street Address:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

If hired, when can you start?

Expected Salary:

Are you currently employed?

Yes No

Education

Highest level of education completed:

School Name and Address:

Work History

First Most Recent

Name of Company and Position Head:

Job Duties:

Employment Dates = From - To:

Starting Wage:

Ending Wage:

Supervisor:

Phone:

May We Contact Them:

Yes No

Second Most Recent

Name of Company and Position Head:

Job Duties:

Employment Dates = From - To:

Starting Wage:

Ending Wage:

Supervisor:

Phone:

May We Contact Them:

Yes No

Third Most Recent

Name of Company and Position Head:

Job Duties:

Employment Dates = From - To:

Starting Wage:

Ending Wage:

Supervisor:

Phone:

May We Contact Them:

Yes No

APPLICANT CERTIFICATION
Read carefully before acknowledging.

The information I have provided is true, to the best of my knowledge, and I understand that false, misleading or omitted information on my application, which is uncovered in a background check, is sufficient reason and cause for rejection of further employment consideration. If already employed by the Companies, this information may result in the termination of my employment.

I further understand that the completion of this application is not an employment contract, or a promise of employment and any promises made are not binding unless made in writing. If I am offered a position at General Partners Insurance Agency, LLC my employment will be conditional upon the adequacy of reference checks and I understand that employment is as an employee at will and I may be terminated at any time at my option or at the option of the company.

I acknowledge the information provided is true to the best of my knowledge.

Date:

Agent Name (Optional):