Coyle Insurance Agency, Inc.

Employment Application

Applicant Instructions

Incomplete applications will not be processed. This application will be considered active for 180 days. Any applicant wishing to be considered beyond this time period should submit another application.

Please note. This application is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all questions completely and accurately. False or misleading statements on this form are grounds for terminating the application process, or, if discovered after employment, terminating employment. Additional testing of job-related skills or for the presence of illegal drugs in your body may be required prior to employment.

Applicant Information

First Name *
Middle Initial
Last Name *
Suffix
Social Security Number *
Address *
City *
ST *
Zip Code *
Home Telephone
Daytime Telephone
Email Address

Position Information

Which position are you interested in?
Comments
Desired Salary
Willing to relocate?	Yes No
Full-Time or Part-Time employment?	Full-time Part-time
If Part-Time, how many hours per week are you available?
What date are you available to start?
Are you at least 18 years of age?	Yes No

Citizenship Information

Are you prevented from being lawfully employed in this country due to a Visa or immigration status?

Yes No

Education Information

High School Name
City
ST
Receive High School Diploma?	Yes No
College/University
City
ST
How many years of College have you completed?
What is/was your course of study?
What was your graduation date/projected graduation date?
Please list all other Schooling:

Job Related Skills

List any languages other than English that you speak fluently:
Mark all skills that apply:	Word Processing 10 Key Adding Machine Typing WPM
List all knowledge of computer programs:
List any other skills:
List any licenses or certifications you have that you feel would be of value to this job or company

Security

Have you ever been bonded in prior employment?	Yes No
Have you ever been convicted of a misdemeanor or a felony?	Yes No If Yes, please explain

Background Authorization

If I am interviewed and accept employment, I agree to allow company to investigate my background.

Yes No

Employment Experience

Please go back 5 years, listing your most recent employer first. Include any gaps in employment and state the reason for no employment during that period.

Employer

Address

City

Zip Code

Phone

Job Title

Supervisor

Start Date

End Date

Starting Salary/Hourly Wage

Ending Salary/Hourly Wage

Reason for Leaving

Employer

Address

City

Zip Code

Phone Number

Job Title

Supervisor

Start Date

End Date

Starting Salary/Hourly Wage

Ending Salary/Hourly Wage

Reason For Leaving

Employer

Address

City

Zip Code

Phone Number

Job Title

Supervisor

Start Date

End Date

Starting Salary/Hourly Wage

Ending Salary/Hourly Wage

Reason for Leaving

References

Include only individuals familiar with your work ability. Do not include relatives. Please do not include individuals to whom you directly reported in the last five years.

	Name, Address, Phone:	# Years Known	Relationship
1.
2.
3.

* indicates required fields

I hereby certify that I have a genuine interest in being hired and that all of the foregoing statements are true and correct. I agree to assume a continuing responsibility to disclose additional or new information, called for by this Employment Application, but known to me only after this Application was completed, and understand that my failure to make such a disclosure, and that falsification of any of the information given herein, on any employment form or in any interview, are grounds for immediate termination, regardless of when such failure or falsification may be discovered.

I also understand that my employment may be terminated at any time, with or without cause, without liability to me for salary, wages, or other benefits except as may have been earned up to date of the termination of services.