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Contact Information
Contact Information
We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status. WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
Name
*
First
Last
Address
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Street Address
Address Line 2
City
State
ZIP
Email
*
Phone
*
Questions
Questions:
Job Applying For:
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How did you hear about Professional Group Plans?
Are you 18 years old or older?
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Yes
No
Can you provide required proof of your eligibility to work?
*
Yes
No
Are you authorized to work lawfully in the USA?
*
* Proof of citizenship or immigration status will be required upon employment.
Yes
No
Please Explain and if so, what date would you be available?
*
Salary Requirment:
*
When are you available to work:
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Check all that apply.
Full-Time
Part-Time
Shift Work
Temporary
Dates you will be available:
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Days Available:
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Monday
Tuesday
Wednesday
Thursday
Friday
On what day are you available to start?
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Can you travel if the job requires?
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Yes
No
Have you ever been involuntary terminated from a job?
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Yes
No
Please explain:
*
Education
Education
High School Name
*
City & State
Diploma/Degree Level
*
Undergraduate College Name
*
City & State
Diploma/Degree Level
*
Graduate School Name
City & State
Diploma/Degree Level
Employment Experience
Start with the Most Recent/Current Employer
Employment: Start with the Most Recent/Current Employer.
Are you currently employed?
*
Yes
No
Can we contact you current employer?
*
Yes
No
Current Employer
*
Date started
*
City & State
*
Job Title
*
List Job Responsibilities
*
Reason for wanting to leave
*
Prior Employers
Prior Employer #1
*
Date Started
Date Ended
City & State
*
Job Title
*
List Job Responsibilities
*
Reason for leaving
*
Add another employer
*
Yes
No
Prior Employer #2
*
Date Started
Date Ended
City & State
*
Job Title
*
List Job Responsibilities
*
Reason for leaving
*
Add another employer
*
Yes
No
Prior Employer #3
*
Date Started
Date Ended
City & State
*
Job Title
*
List Job Responsibilities
*
Reason for leaving
*
Add another employer
*
Yes
No
Prior Employer #4
*
Date Started
Date Ended
Job Title
*
City & State
*
List Job Responsibilities
*
Reason for leaving
*
Add another employer
*
Yes
No
Prior Employer #5
*
Date Started
Date Ended
Job Title
*
City & State
*
List Job Responsibilities
*
Reason for leaving
*
List professional, trade, business, or civic activities and offices held. You may exclude memberships which would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status:
Other Qualifications: Summarize special job-related skills and qualifications acquired from employment or other experience.
References
Please give us three References.
Name
*
First
Last
Relationship?
*
Phone
Email
Name
*
First
Last
Relationship?
*
Phone
Email
Name
*
First
Last
Relationship?
*
Phone
Email
Applicant Statement
Applicant Statement
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT, IF HIRED, MY EMPLOYMENT RELATIONSHIP WITH THIS ORGANIZATION WOULD BE OF AN “AT WILL” NATURE, WHICH MEANS THAT THE EMPLOYEE MAY RESIGN AT ANY TIME AND THE EMPLOYER MAY DISCHARGE THE EMPLOYEE AT ANY TIME AND FOR ANY OR NO REASON. IT IS FURTHER UNDERSTOOD THAT THIS “AT WILL” EMPLOYMENT RELATIONSHIP MAY NOT BE CHANGED BY ANY WRITTEN DOCUMENT OR CONDUCT UNLESS SUCH CHANGE IS SPECIFICALLY ACKNOWLEDGED IN WRITING BY AN AUTHORIZED EXECUTIVE OF THIS ORGANIZATION. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Do you certify that the above statement is true?
*
Yes
No
Signature
*
Date
*
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