Secure Employment Application

Your Name:

First	Last

Email Address:

Phone Number:

5 Digit Zip:

Main Street 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 Main Street 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):

Website Disclaimer - Review Carefully:

This is a solicitation for insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voicemail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.