My Mail Form

Name:
Email:
Address:
City:
State:
Zip Code:

Date of Birth*:
Foreign Languages:
Insurance Adjusting License:
Special Qualifications:

*The Age Discrimination in Employment act of 1967 prohibits discrimination on the basis of age with respect to individuals who are least 40 but less than 70 years of age.

Have you ever been convicted of a felony in the last 5 years?
Have you ever been convicted of a Misdemeanor in the last 5 years?
Describe:

Work History: Start with most recent & note if we should not contact at this time.

Employer:
Address:
Telephone:
Postion(s):
Dates of Employment:
Salary:

Employer:
Address:
Telephone:
Postion(s):
Dates of Employment:
Salary:

Employer:
Address:
Telephone:
Postion(s):
Dates of Employment:
Salary:

Employer:
Address:
Telephone:
Postion(s):
Dates of Employment:
Salary:

Education History: Start with most recent

College:
Address:
Degrees(s):
Dates:

College:
Address:
Degrees(s):
Dates:

Trade School
Address:
Degrees(s):
Dates:

High School
Address:
Graduated:
Dates:

References: Names of three persons not related to you, whom you have known at least one year.

Reference:
Address:
Phone:
Business:

Reference:
Address:
Phone:
Business:

Reference:
Address:
Phone:
Business:

Physical Record: Do you have any physical limitations that preclude you from performing any work for which you are being considered. If yes, what can be done to accomodate your limitation:

Certification: I certify that answers given are true and complete. I authorize investigation myself, which may include, criminal, civil, credit, driving history, etc., and of all statements contained in this application for employment, as may be necessary in arriving at my employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means the Employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signed:
Date:

Resume: Paste below:

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