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175 N. Bever Street Wooster, Ohio
Call:
(330) 264-9164
1516 W. High Street Orrville, Ohio
Call:
(330) 682-0396
700 E. Main St Ashland, Ohio
Call:
(419) 281-6996
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Employment Application
Employment Application
Position Applied for:
Application Date:
MM slash DD slash YYYY
Personal Information
Name
First
Middle
Last
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Alternate #
Are you available to work:
Full-time
Part-time
If you are under 18 years of age, can you provide required proof of work eligibility?
Yes
No
Have you ever worked or submitted an application with this agency before?
Yes
No
If yes, when:
Are you currently employed?
Yes
No
May we contact your current employer?
Yes
No
Are you eligible to work in the United States? (Proof of eligibility will be required upon employment)
Yes
No
Have you ever been convicted of a criminal offense? (List details below if yes)
Yes
No
Details:
Have you ever filed for bankruptcy as an individual or an entity? (List details below if yes)
Yes
No
Details:
Do you have a valid driver’s license?
Yes
No
Do you have a reliable means of transportation?
Yes
No
Have you ever been discharged from any employment or been asked to resign? (If yes, attach explanation.)
Yes
No
Explanation:
Are you bound by any agreement(s) (including signing a non-competition, non-disclosure, or non-piracy agreement) that would limit your ability to work for the agency? (If yes, attach copy to this application.)
Yes
No
Employment
(Start with most recent employment and work backwards)
Employer
Phone
Full Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Ending Compensation
Reason for Leaving
Describe work performed
Employer
Phone
Full Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Ending Compensation
Reason for Leaving
Describe work performed
Employer
Phone
Full Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Ending Compensation
Reason for Leaving
Describe work performed
Education
School Name
School Address
Grade Completed / Degree
Subjects Studied
Licenses
List state & license # of any licenses you have below:
P&C License
L&H License
Brokers License
Series 6 or 7 License
Other Licenses (Describe)
Designations
CIC
CPCU
CLU
ChFC
CRM
CISR
Other
List Any Other Designations
Software
Microsoft Word
Skill Level
Low
Medium
High
Version
Microsoft Excel
Skill Level
Low
Medium
High
Version
Microsoft PowerPoint
Skill Level
Low
Medium
High
Version
Microsoft Outlook
Skill Level
Low
Medium
High
Version
APPLIED
Skill Level
Low
Medium
High
Version
AMS
Skill Level
Low
Medium
High
Version
Other:
Skill Level
Low
Medium
High
Version
Other:
Skill Level
Low
Medium
High
Version
Other:
Skill Level
Low
Medium
High
Version
References
Name
Company Name
Address
Phone
Occupation
Relationship
Additional Experience or Qualifications
List any other experience, skills or qualifications that you believe should be considered in evaluating your qualifications for employment.
Notification and Agreement
(Please read before submitting)
It is Vaughan Insurance Agency’s policy to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or sexual orientation, individuals with a disability, or any other characteristic protected by applicable Federal, State or Local law.
I authorize the investigation of all statements and information contained in this application. I release from liability anyone supplying such information and I also release Vaughan Insurance Agency from all liability that might result from making an investigation
If employed, I agree to not engage in any outside activity that would involve a material conflict of interest with, or could reflect adversely on Vaughan Insurance Agency. I understand that Vaughan Insurance Agency retains the right to solely decide when such conflict exists.
If employed, I agree to hold in strictest confidence any information concerning Vaughan Insurance Agency, its Insureds, and its Carriers that may come to my knowledge.
In consideration of my employment, if I am employed, I agree to conform to the employment policies of Vaughan Insurance Agency, and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Vaughan Insurance Agency or myself. I understand that no representative of Vaughan Insurance Agency, other than the President, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.
I understand that completion of this employment application does not guarantee that I have been employed by Vaughan Insurance Agency.
I certify that all answers given by me are true, accurate and complete, I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
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