Online Employment Application
Please fill out completely. Thank you.
Personal Information
first name
middle initial
last name
address
city
state
zip
preferred phone
alternate phone
fax number
e-mail address
Employment Desired
position
how did you hear of this position?
date available (mm/dd/yyyy)
Education
school name and address
course of study
yrs
degree/diploma
list any seminars, classes or other education not listed above which may help qualify you for this position:
Employment History
List below your last three employers starting with your most recent employer. Account for all periods of unemployment.
may we contact yourcurrent employer?
employer
start (mm/dd/yyyy)
end (mm/dd/yyyy)
phone
supervisor
position(s)
starting salary
ending salary
essential job functions of final position
reason(s) for leaving (or wanting to leave)
what value did you add to this company or its customers?
reason(s) for leaving
Additional Information
list any professional, trade, business or civic activities and offices held (you may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability or any other protected status)
list any languages other than english that you can speak, read or write rate yourself as "fluent", "good" or "fair" in each area
identify formal job training that relates to this position
identify skills or certifications you possess related to this position
if hired, what value would you bring to our company
describe what you believe are the most unique features of your work history
have you been employed by slaton insurance before? if yes, when?
do you have any friends or relatives employed by slaton insurance? if yes,state their names and relationship to you
are you currentlyemployed?
are you on "lay off" statusand subject to recall?
if you are under 18, can youprovide proof of eligibility to work?
if hired, can you provide proof of u.s. citizenship or proof of your legal right to work in the u.s.?
are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accomodation?
are there any accomodations the company would need to provide so that you can perform all essential functions and duties of the positions being applied for? if yes, please explain
if driving is a requirement of the position applied for, have you in the last 7 years been convicted of driving under the influence (dui)?
do you have a reliable means of transportation?
are you able to travel or work overtime or weekends as needed?
Criminal Record
INSTRUCTIONS FOR ANSWERING APPLICATION QUESTION ABOUT BEING CONVICTED OF A CRIME OR OTHER STATE-SPECIFIC REQUIREMENTS Please respond to the following questions in the most complete and accurate manner possible. Do not identify convictions for convictions for which the criminal record has been expunged or sealed by the court or, misdemeanor convictions for which any probation has been completed and the case dismissed by the court. Furthermore, please note that no applicant will be denied employment solely on the grounds that they have been charged, committed, or convicted of (or pleaded guilty or no contest in) a criminal offense, or solely on an affirmative answer. The nature, date, surrounding circumstances and relevance of the offense to the position(s) applied for will be considered. A criminal record does not constitute an automatic bar to employment and will be considered only as it substantially relates to the job in question. If you are applying for a position with our company in the following states, please read the instructions which follow below before responding.
have you ever, under your name or another name, been convicted of (or pleaded no contest to) a felony or misdemeanor?
have you ever, under your name or another name, been convicted of a crime, which resulted in your being in prison and/or jail and released from prison and/or jail or paroled?
if yes to either question above, please fully explain when, where and of what you were convicted and the result of the case(s)
are you currently under arrest, or released on bond on your own recognizance, pending trial for a criminal offense? if yes, state the nature of the crime charged, and when and where the trial is pending
have you used illegal drugs in the last six months?
do you take illegal drugs or medications that have not been prescribed for you?
if yes, to either of the above questions, when was the last time you used illegal drugs?
have you ever been convicted of driving under the influence (dui)?
do you use alcohol to the extent that it would impair your job performance?
are you able to perform the essential function of the job you are applying for (with or without reasonable accommodation)? if no, describe the functions that cannot be performed
References
List below three persons not related to you who have knowledge of your work performance within the last 5 years
name
occupation
company name
e-mail
relationship & years acquainted
Acknowledgements
Please read each statement carefully and initial each to acknowledge your understanding.
initial
Equal Opportunity Statement This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.
Discrimination and Sexual Harassment Policy Statement This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.
Disclosure to Applicants Concerning Drug/Alcohol Testing If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.
Complete and Accurate Information I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
At-Will Employment I understand and agree that if I am employed, my employment will be “at-will”, which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superceded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by the Company’s president.
Testing Authorization If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.
Investigation Authorization I authorize investigation into all statements and references contained in this application. Said investigation may include interviews with past employers, workers and friends. Said investigation may include credit, driving, criminal background, references and other background checks. As a condition of applying for this job, I authorize reasonable post-hire investigations into my credit, driving and criminal background.
Company Obligation I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application.
MY ANSWERS HAVE BEEN TRUE AND ACCURATE PURSUANT TO THE PENALTY OF PERJURY UNDER THE LAWS OF THIS STATE. I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.
electronic signature (please type your full legal name)
if you have a resume (must be in word, rtf, pdf or plain text format) to submit with this application, please browse and select the file:
