Career
in Chicagoland

I. Personal Information

Have you ever been involuntarily terminated or requested to resign?*
YesNo

If hired, can you provide verification of your legal right to work in the United States?*
YesNo

Social Security Number*

If you are under age of 18, do you have a work permit?*
YesNoN/A

If required for the position, do you have a valid drivers license?*
YesNo

If hired, would you have reliable transportation to and from work?*
YesNo

Have you ever worked under a different name?*
YesNo

If 'Yes' Your Other Name

Do you have friends or relatives working for our company?*
YesNo

If 'Yes', Name & Relationship

Emergency Contact Name*

Emergency Contact Phone*

Have you ever been convicted of a felony? (convictions will not necessarily disqualify you for this position)*
YesNo

If 'Yes' list offense, Date and Disposition of the Case

II. Employment Interests

Position Desired*
Please chooseInsurance AgentCustomer ServiceManagement

Date Available*

Pay Desired ($)*

Please leave this field empty.

Type of Employment Desired*
Full-TimePart-timeRegularTemporary

Would you be willing to work overtime?*
YesNo

Days and Hours available for work*

How were you referred to our company?*
Please chooseAdEmployee ReferralAgencyWalk-InOther

Referred by

III. Education Information

School Level*
Please chooseHigh SchoolCollege/UniversityPost GraduadeBusiness/Trade

Name and Location of School*

Course of Study*

Last grade completed*
123N/A

Did you graduade?*
YesNo

Received?*
DegreeDiploma

IV. Skills

Typing speed (wpm)

10-key by Touch
YesNo

Foreign Language(s)

Foreign Language Proficiency
SpeakReadWrite

PC Skills (indicate software used)

Other Skills

Do you have any experience, training, qualifications or skills which you think make you expecially suited for work at this company? (Explain)

V. Employment Information

Start with Current or Most Recent Employer.

Company 1

Company Name*

Phone Number*

Address, City, State, Zip*

Job Title*

Supervisor/Manager*

Job Duties*

Company 2

Company Name

Phone Number

Address, City, State, Zip

Job Title

Supervisor/Manager

Job Duties

Company 3

Company Name

Phone Number

Address, City, State, Zip

Job Title

Supervisor/Manager

Job Duties

VI. Acknowledgment

I authorize any person, school, current employer (except as expressly noted), past employer(s), and organizations named in this application form (and accompanying resume or other documentation, if any) to provide ATLANTIC INSURANCE AGENCY with relevant information and opinion, personal or otherwise, that may be useful in making a hiring decision. I release all parties from all liability from any damage that may result from furnishing information and opinion to you.

In consideration of employment, I agree to obey the rules and standards of ATLANTIC INSURANCE AGENCY. I understand that nothing contained in this application or in the interview process is intended create a contract between ATLANTIC INSURANCE AGENCY and myself for either employment or for the providing of any benefits. I agree that my employment is at-will and the terms of employment may be changed with or without cause, with or without notice, including but not limited to termination, demotion, promotion, transfer, compensation, benefits, duties and location of work, at any time, for any reason, at the option of myself or ATLANTIC INSURANCE AGENCY. This constitutes my entire agreement with ATLANTIC INSURANCE AGENCY with regard to the length of my employment.

I understand that as a condition of employment I may be required to take a post-offer/pre-employment physical examination that may include an alcohol and drug test. I further understand that at any time during my employment, I may be required to take a physical examination which may include an alcohol and drug test if management reasonably suspects a condition exists that will prevent me from performing my job in a manner that does not endanger my own health or the safety and health of others. I authorize all providers of health care who examine me to disclose to ATLANTIC INSURANCE AGENCY or its agents, all medical information revealed during such examinations. I further authorize ATLANTIC INSURANCE AGENCY to disclose such information to any other persons, if at any time my medical condition is put at issue in any proceeding by myself or others. In the event that I have credibility that will affect my ability to take the test, I will so inform ATLANTIC INSURANCE AGENCY so that a reasonable accommodation can be made. ATLANTIC INSURANCE AGENCY reserves the right to require medical documentation concerning the need for accommodation.

I understand that all offers of employment are conditioned upon my providing satisfactory documentary proof of my identity and legal right to live and work in the United States.

I hereby acknowledge that I have read the above statements and understand them. I certify that I, the undersigned applicant, have personally completed this application. I declare under penalty of perjury that the facts contained in the application (or any resume or other documents submitted) are true and complete to the best of my knowledge. I understand that any misrepresentations or omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment, if discovered at a later date.

Please read carefully and place a check before you submit to indicate you agree.