Application for Employment

We are always looking for professional agents to join our network. We offer a top commission schedule and lead generation along with full CSR support of your clients so you can spend your time selling. We also offer something very unique, "OWNERSHIP OF YOUR BOOK"

Please print and fill out the application below and return by mail to:

Or to the attention of Manager by fax at: (651) 451-0301

EMPLOYMENT APPLICATION
Position applied for: __________________________________________________
Name:____________________________________________________________
Date:____/___/________

We appreciate your interest in employment. Please read carefully and complete all items. Your answers will help us consider you. If you have any questions, please ask. Incomplete or incorrect information could prevent consideration. Your application will be kept active for 60 days and must be renewed in person if you wish continued consideration. You will only be contacted if there is a job opening and we wish to interview you.

We comply with all applicable Federal and State equal employment opportunity laws. All qualified applicants will be considered for all positions based on their qualifications without regard to national origin, age, sex, color, race, religion or handicap.
IDENTIFICATION
Referral Source: Friend Relative Employment Agency
Employee Advertisement Internet Other

Last Name:_______________________________________

First Name:_______________________________________

MI__________

Street Address:____________________________________

City:______________________State:_____ Zip:__________

Phone:(_________)_________________________________
Social Security Number:______________________________
Date Available to begin employment:_____________________
Type of Position Desired: Full Time Part Time Temporary

Are you:

18 Years of age or older?

Under 18 Years of age?

If under 18 are you able to provide a work permit?
Yes No
Are you on layoff and subject to recall? Yes No

Have you ever been convicted of a felony or a misdemeanor (other than minor traffic violations) within the last 7 years?
Yes No

If yes, please describe in full detail (include dates).

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Conviction of a crime is not a bar to employment. All circumstances will be considered.
PERSONAL REFERENCES
List business, work, school, or personal references. Do not list relatives or previous supervisors.
NAME AND ADDRESS
PHONE
OCCUPATION
YEARS KNOWN
       
       
       
EDUCATIONAL BACKGROUND
School Name
Years Completed
Elementary
4
5
6
7
8
High School:
9
10
11
12

College/University:

Diploma/Degree:
Course of Study:
1
2
3
4
EMPLOYMENT EXPERIENCE

List each position held starting with present or most recent position. Include military experience.

Employer
Dates
Address:
From
To
 Describe Duties
Telephone: Hourly Rate/Salary
Job Title:
Starting
Final
Supervisor:
Reason for Leaving:
May we contact for reference? Yes No
Employer
Dates
Address:
From
To
 Describe Duties
Telephone: Hourly Rate/Salary
Job Title:
Starting
Final
Supervisor:
Reason for Leaving:
May we contact for reference? Yes No
Employer
Dates
Address:
From
To
 Describe Duties
Telephone: Hourly Rate/Salary
Job Title:
Starting
Final
Supervisor:
Reason for Leaving:
May we contact for reference? Yes No
OTHER QUALIFICATIONS

Describe any training, special skills, qualifications, other experience that may qualify you to work with our company. Please also include explanations for gaps in employment not covered above. If additional space is needed, please attach a separate sheet of paper:

 
 
 
 
 
 

 
AGREEMENT

I certify that the information contained in this application is true and complete ti the best of my knowledge and understand that, if employed, falsification of this information and/or omission of fact shall be grounds for dismissal in accordance with the policies of Reliable Insurance Network. I hereby authorize investigation of all statements contained herein , the references listed and previous employers, if marked, to give you any and all information concerning my precious employment and any pertinent information they may have, personal or otherwise, and release of all parties from any liability for any damage that may result from furnishing same to you.

I understand that all persons hired by Reliable Insurance Network will be required to comply with the Immigration Reform and Control Act of 1986. Any off of employment will be contingent upon my ability to show proof of identity plus proof of eligibility to work in the United States of America as outlined by the Immigration and Naturalization Service.

I understand that my employment can be terminated at any time, at my option or the option of Reliable Insurance Network, with or without cause and without prior notice. I understand that any exceptions to the employment policy of Reliable Insurance Network (including any agreement for employment for any specified period of time) must be in writing and must be signed by the President of Reliable Insurance Network. I understand that no representative of Reliable Insurance Network has the authority to make any assurance to the contrary.

Date:____/____/_________

Signature:_________________________________________________