Application for Employment

Name: C.L. Van Deventer Insurance Agency
Address: 123 W. Chicago Road, Sturgis, MI, 49091, US
Telephone: (269) 651-8066

C.L. Van Deventer Insurance Agency is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
Personal Information
Incomplete information could disqualify you from further consideration.
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Position Sought
Type of Employment
- Full Time
- Part Time
Date Available
MM slash DD slash YYYY
Salary Desired
Are you over 18 years old?
- Yes
- No
Are you legally eligible for employment in the United States?  (If offered employment, you will be required to provide documentation to verify eligibility.)
- Yes
- No
Have you ever been terminated from employment or asked to resign by an employer?
- Yes
- No
If yes, please provide company names and details:
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?
- Yes
- No
Are you currently employed?
- Yes
- No
If so may we inquire of your present employer?
- Yes
- No
Current Employer Contact Information:
Referral Source
How did you hear about us?
- Walk In
- Advertisement
- Referral
- Other
Have you ever worked for this company before?
- Yes
- No
If yes, explain:
Do you know anyone who works for our company?
- Yes
- No
If yes, who?
Education
High School
Name and location of school Years Attended Degree Received Subjects Studied/Major
College or University
Name and location of school Years Attended Degree Received Subjects Studied/Major
Trade, Business or Correspondence School
Name and location of school Years Attended Degree Received Subjects Studied/Major
Employment History
Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.
Job 1
Dates Employed Employer Name Phone
Job Title Address Immediate Supervisor and Title
Responsibilities Reason for Leaving Hourly Rate/Salary
Job 2
Dates Employed Employer Name Phone
Job Title Address Immediate Supervisor and Title
Responsibilities Reason for Leaving Hourly Rate/Salary
Job 3
Dates Employed Employer Name Phone
Job Title Address Immediate Supervisor and Title
Responsibilities Reason for Leaving Hourly Rate/Salary
Job 4
Dates Employed Employer Name Phone
Job Title Address Immediate Supervisor and Title
Responsibilities Reason for Leaving Hourly Rate/Salary
Job 5
Dates Employed Employer Name Phone
Job Title Address Immediate Supervisor and Title
Responsibilities Reason for Leaving Hourly Rate/Salary
Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain:
Computer Skills (please describe)
References
Give the names of three persons not related to you, whom you have known at least three (3) years.
List
Name Address, Phone, Email Company Years Acquainted
Please read carefully before submitting
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for C.L. Van Deventer Insurance Agency to hire me. If I am hired, I understand that either C.L. Van Deventer Insurance Agency or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of C.L. Van Deventer Insurance Agency has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to C.L. Van Deventer Insurance Agency true and complete information on this application. No requested information has been concealed. I authorize C.L. Van Deventer Insurance Agency to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE SIGNED/DATED ABOVE.

Δ

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Sturgis Office

C.L. Van Deventer Insurance Agency

123 W. Chicago Road
Sturgis, Michigan 49091

Phone: (269) 651-8066

Mon-Fri: 9:00am-5:00pm
Sat-Sun: Closed

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Battle Creek Office

C.L. Van Deventer Insurance Agency

100 Helmer Road North
Battle Creek, Michigan 49037

Phone: (269) 924-3001

Mon-Fri: 9:00am-5:00pm
Sat-Sun: Closed

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C.L. Van Deventer Insurance Agency specializes in Auto/Car Insurance, Homeowners Insurance, Business/Commercial Insurance, Life Insurance, and Workers’ Compensation Insurance for all of Michigan, including Burr Oak, Colon, Sturgis, Centreville, Three Rivers, Mendon, White Pigeon, Athens, Bronson, Coldwater, Constantine, Howe. In, LaGrange, In., Leonidas, Quincy, Union City, Marshall, Portage, Kalamazoo, Springfield, Delton, Albion, East Leroy Township, Homer, Pennfield Township, Emmett Township, Bedford Township, Tekonsha Township, Burlington, Fredonia Township, Marengo Township, City Of Battle Creek, and Lakeview.

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Name and location of school	Years Attended	Degree Received	Subjects Studied/Major

Name	Address, Phone, Email	Company	Years Acquainted

Application for Employment

Personal Information

Referral Source

Education

Employment History

References

Please read carefully before submitting