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Application for Employment
Application for Employment
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
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