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EMPLOYMENT FORM:

This is a very important document. Be careful as you complete each section.

Answer each item accurately and completely. Failure to do so may result in your
not being considered for the position, or in your termination if inaccurate or omitted
information is discovered after your employment has begun.

Position Desired:

How did you hear about us:

First Name:
Last Name:
Social Security Number:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
_______________________________________________________________________________________________________________

WORK HISTORY
Company Name:
Address:
Phone Number:
Job Title:
Salary (Excluding bonuses or commissions):
Supervisor:
Start Date:
End Date:
May We Contact:
Reason For Leaving:
Description of duties: :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Company Name:
Address:
Phone Number:
Job Title:
Salary (Excluding bonuses or commissions):
Supervisor:
Start Date:
End Date:
May We Contact:
Reason For Leaving:
   
Description of duties: :
      
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Company Name:
Address:
Phone Number:
Job Title:
Salary (Excluding bonuses or commissions):
Supervisor:
Start Date:
End Date:
May We Contact:
Reason For Leaving:
   
Description of duties:
      
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
REFERENCES
Reference Name:
Company:
Postion:
Phone:
Reference Name:
Company:
Postion:
Phone:
Reference Name:
Company:
Postion:
Phone:
Reference Name:
Company:
Postion:
Phone:
_______________________________________________________________________________________________________________

EDUCATION

High School:
City:
Graduate:
Yes: No:
College:
Number of Years:
Graduate:
Yes: No: 		Degree/Certificate Earned:
College:
Number of Years:
Graduate:
Yes: No: 		Degree/Certificate Earned:
Insurance Licenses/Certificates/Designation:
 		Are you familiar with the Fair Claims Act?:
Yes: No: 		Are you certified with the FCA?:
Yes: No: 		When were you last certified & by whom?
_______________________________________________________________________________________________________________

DESIRED EMPLOYMENT

Availability:
Temp: Perm: 		Salary Desired:
Least Acceptable Salary:
Please list all companies
you are currently pending at:
Please list the companies you
have sent a resume to in the past year:
Are you able to perform the essential functions of the job(s) for which you are applying with or without accommodation?:
Yes: No: 		Do you take illegal drugs?
If yes, please describe:
Do you use alcohol to the extent that it would impair your job performance?  If yes, describe:
 		What are you looking for in a new position?:
 		Are you willing to relocate? 
If yes, to what areas:
 		What areas are you willing to drive to:
_______________________________________________________________________________________________________________

CONTACT INFORMATION

      
Due to the frequency that people move, we would like a permanent address or contact where you can be reached:
Name:
Relationship:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
_______________________________________________________________________________________________________________
CRIMINAL MATTERS      
Have you ever been convicted of, pleaded guilty or “no contest” to a crime?  Do not identify marijuana related misdemeanor convictions occurring more than two years ago, or convictions for which the criminal record has been expunged, sealed, or eradicated by the court, or misdemeanor convictions for which any probation has been completed and the case dismissed by the court.

Yes: No:
Did the conviction(s) or guilty or “no contest” plea result in imprisonment?

Yes: No:   		If yes, please list number of times:
Explain each conviction and guilty or “no contest” plea fully.
A conviction or guilty or “no contest” plea will not necessarily disqualify an applicant:
    
Are you currently charged with an unresolved criminal charge ?

Yes: No:    

(a charge which has not yet resulted in a plea, trial or dropping of the charge, or for which you are out on bail or on your own recognizance pending trial.)

If yes, explain fully. A charge will not necessarily disqualify an applicant:

    
_______________________________________________________________________________________________________________
A representative from QA Insurance Staffing should be in contact with you soon.

THANK YOU.		    
     
       
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