EMPLOYMENT APPLICATION FORM

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

Please complete pages 1-5.
Attach a current passport size picture. (optional)
Attach copies of all diplomas and certificates. (required)
Attach a copy of Identification (ID, Passport or License). (required)
Date:
Name:
  Last First Middle Maiden
Date of Birth: I.D. No.: Sex Male
  Female 
Present Address:
Number
Street
City
Country
Civil Status: Married  Children Yes  E-mail:
   Single   No   
Telephone No.   Nationality:  
Home:
Mobile:
   
Position Applied For:
Salary Desired:
Are you eligible for employment? Yes No
If yes, attach relevant documentation.
Days/Hours Available to Work:
No Pref.   Thu
Mon Fri
Tue Sat
Web Sun
Employment Desired: Full-time only  Vacation Only Intern/Job Training 
When available for work?
EDUCATION & OTHER INFORMATION
TYPE OF SCHOOL NAME OF SCHOOL LOCATION
(Complete mailing address)
NO. OF YEARS COMPLETED MAJOR & DEGREE OBTAINED
High School
College
College
Bus. Or Trade School
Professional School
Persons to contact in the case of an emergency:
Name:
Name:
Phone Number:
Phone Number:
Second Phone Number:
Second Phone Number:
Address:
Address:
Relationship to applicant:
Relationship to applicant:
Please list your computers skills if any:
 
Have you ever been convicted of a crime? Yes No
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
Do you have a driver's license? Yes No
Driver's License Number:
Place of Issue:
Expiration Date:
Class: A B C D E
Please list two references other than relatives or previous employers.
Name:
Name:
Position:
Position:
Company:
Company:
Address:
Address:
Telephone:
Telephone:
Amount of years known:
Amount of years known:
An application from sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to add any additional information necessary to describe your full qualifications for the specific position for which you are applying.
 
Work Experience Please list your work experience beginning with your most recent job held.
Attach additional sheets if necessary.
Job One
Name of Employer:

Name of Last Supervisor:

Employment Dates:
From:
To:
Complete Address:
Phone Number:
Your last Job Title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
 
Job Two
Name of Employer:

Name of Last Supervisor:

Employment Dates:
From:
To:
Complete Address:
Phone Number:
Your last Job Title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
 
Job Three
Name of Employer:

Name of Last Supervisor:

Employment Dates:
From:
To:
Complete Address:
Phone Number:
Your last Job Title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
 
Job Four
Name of Employer:

Name of Last Supervisor:

Employment Dates:
From:
To:
Complete Address:
Phone Number:
Your last Job Title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
 
Job Five
Name of Employer:

Name of Last Supervisor:

Employment Dates:
From:
To:
Complete Address:
Phone Number:
Your last Job Title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
 
Job Six
Name of Employer:

Name of Last Supervisor:

Employment Dates:
From:
To:
Complete Address:
Phone Number:
Your last Job Title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
 
May we contact your present employer? Yes No
May we contact your previous employer? Yes No
 
PLEASE READ CAREFULLY
APPLICATION FORM WAIVER

In exchange for the consideration of my job application by NAGICO Insurances (hereinafter called “the Company”), I agree that:
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts will result in my application not being considered for employment. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I further understand that my employment with the Company shall be probationary for a period of two (2) months, and further that any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

I herby confirm that the information contained in this job application is complete and accurate.
Signature of Applicant Date:

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.





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