Application

In order for your credentials to be given full consideration, please use ink and complete this application in its entirety.
Please print or type all information requested except signature.
Last name __________________________________ First name ________________________ Middle ___________
Social Security #_______________________________ Date ___________________________
Address _______________________________________________________________________________________
Street/Apartment City State Zip
Telephone _____________________________ E-mail _____________________________
Position applied for _________________________________________________________

Position desired
■ Full-time ■ Part-time Full or part-time date available for employment ________________________
Salary desired _____________________

Personal information
■ Yes ■ No Are you legally eligible to work in this country? (You must be authorized to work in the United States at the time of hire
for purposes other than practical training and without employer sponsorship of non-immigrant work visa.)
■ Yes ■ No Are you under 18? (Federal or state law limits employment for certain positions for individuals under 18 years of age. In
some cases, a work permit is required.)
■ Yes ■ No Have you ever pled guilty to or been convicted of any crimal offense other than a minor traffic violation?
(If yes, explain below. Include number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s)
was/were, sentence imposed and type of rehabilitation. Use additional paper if necessary. You are not obligated to disclose
sealed or expunged records of a conviction or arrest….only applies to IL _____________________________________________
_______________________________________________________________________________________________________
■ Yes ■ No Are you a U.S. veteran? If yes, complete the following:
Specialty or training ______________________________Branch of service _____________________

Number of yrs Diploma/ Major/minor

Type of school Name of school
completed degree
High School
Jr. College

College/University

Other

Specialized skills/licenses/certifications Active state licenses, registrations, designations

■ Personal computer ■ CIA ■ NASD Series 6 ■ ACS

■ Microsoft Word ■ EXCEL ■ Other ___________ ■ CPA ■ Property & Casualty ■ CCP
■ Typing/Keying _______ wpm ■ FLMI ■ Life/Health
■ Calculator ■ CLU/ChFC ■ LUTCF
■ Other _____________________________________ ■ CPCU ■ IIA
■ Other _______________________________

Currently appointed with (company(ies): Current license(s) expiration date:

1.
2.
3.

AM-001431 (6/05) Page 1 of 3

Work history
Employer Reason for leaving

Address Salary

Phone May we contact

■ Yes ■ No
Responsibilities

Employer Reason for leaving

Address Salary

Phone May we contact?

■ Yes ■ No
Responsibilities

Employer Reason for leaving

Address Salary

Phone May we contact?

■ Yes ■ No
Responsibilities

AM-001431 (6/05) Page 2 of 3

Work history (Cont.)
Employer Reason for leaving

Address Salary

Phone May we contact

■ Yes ■ No

Responsibilities

________________________________________________________________________________________________

References
List four work/business/school references (not related to you). Include telephone number and/or e-mail address.

1. 2.

3. 4.

I attest that I have completed this application completely and honestly. I understand that references may be contacted
and hereby authorize such contact. I further understand that any false information listed on this application subjects me
to being denied employment or, if hired, termination.

______________________________________________ ______________________
Signature of applicant Date

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