6/23/2017

Personal Data (1 of 8)

Full Name:
Contact Information:
Current Address:
 
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Employment History (2 of 8)

Please give accurate and complete information. Start with present or most recent employer, including self-employment, part-time work, military employment, and any work performed on a volunteer basis. Account for your entire employment history, including significant gaps in your employment. All information must be included, even if you are attaching a resume.

Employer 1 (All Fields Required)

Employer 2

Employer 3

Employer 4

Education (3 of 8)

List all colleges whether or not degree was obtained.

  Name Location Major Minor Degree/ Certification
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3.
  Begin Year End Year # Years Attended
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2.
3.

Skills and Qualifications (4 of 8)

List any special training, experience, qualifications or skills relevant to the position for which you are applying (i.e., MS Office, Accounting, Payroll, Marketing, Sales, etc.):

Languages (5 of 8)

List the languages that you know and check whether you can speak and/or write them.

Language Speak Write

References (6 of 8)

Give name, work relationship, and telephone number of three supervisors/managers or other professional reference that are not related to you. (All 3 Required)

Security (7 of 8)

*In answering this question, you are not obligated to disclose any convictions that have been sealed, annulled, expunged, dismissed, erased, impounded, cleared, vacated or officially pardoned. Before answering, please review the specific state exceptions below.
California applicants only: Applicants need not identify convictions that have been sealed, expunged, dismissed or otherwise eradicated by statute or court order, or any information pertaining to referral to and participation in any pre-trial diversion program. Applicants may omit any conviction for Marijuana-related offenses that are more than two years old; any offense which was finally settled in juvenile court or referred to the youth authority; any misdemeanor conviction for which for which probation has been successfully completed or otherwise discharged AND the case has been judicially dismissed pursuant to Penal Code section 12034.
Georgia applicants only: You may exclude any conviction that has been discharged under the First Offender’s Law.
Illinois applicants only: A conviction record will not necessarily be a bar to employment. Applicants are not obligated to disclose sealed or expunged records of conviction or arrest or expunged juvenile records of conviction or arrest. Applicants may answer “no record” to inquiries about convictions or arrests in which the records have been sealed or expunged, or to inquiries about juvenile records of convictions or arrests in which the records have been expunged.
NOTE: A conviction record will not necessarily be a bar to employment. This information will only be used for job-related purposes consistent with applicable law. Failure to honestly answer this question will result in discontinued consideration of your application or termination of your employment.

Signature (8 of 8)

READ CAREFULLY BEFORE SUBMITTING THIS APPLICATION AS THESE ITEMS REPRESENT SIGNIFICANT MATTERS IN CONNECTION WITH YOUR APPLICATION:

This Organization Participates in E-Verify.

Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States.

This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s Form I-9 to confirm work authorization. IMPORTANT: If the Government cannot confirm that you are authorized to work, this employer is required to provide you with written instructions and an opportunity to contact DHS and/or the SSA before taking adverse action against you, including terminating your employment. Employers may not use E-Verify to prescreen job applicants and may not limit or influence the choice of documents presented for use on the Form I-9. In order to determine whether Form I-9 documentation is valid, this employer uses E-Verify’s photo matching tool to match the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and Immigration Services’ (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 800-255-7688, 800-237-2515 (TDD) or at www.justice.gov/crt/osc.

I certify that the statements and information furnished by me in this application are true and correct. I understand that omitted, false or misstated statements on this application are grounds for refusal to hire, or dismissal, at any time the company becomes aware of the omitted, falsified or misstated information.

I understand that Appalachian Underwriters, Inc. is not obligated to provide me with employment and that I am not obligated to accept employment. I understand that nothing contained in this application, conveyed during any interview that may be granted or during my employment, if hired, is intended to create a contract for continued employment with Appalachian Underwriters, Inc., except as required by applicable federal, state and local law. In addition, if an employment relationship is established, unless I am employed in Montana, I acknowledge that my employment and compensation can be terminated, with or without cause and with or without notice at anytime, at the option of either the Company or myself, and that this cannot be altered except by an express written agreement signed by myself and a designated officer of the Company. I further understand and agree that no manager or other representative of the Company has the authority to make any verbal promises or commitments to me with respect to any term, condition or privilege of my employment including compensation. I further understand that no policy, benefit or procedure creates a contract for continued employment. I understand and agree that, if hired, I will be required to abide by all rules and regulations of and that my wages, benefits and conditions of employment can be changed by the Company at any time at its sole discretion.

I agree and herby authorize Appalachian Underwriters, Inc to conduct a background inquiry to verify the information on this application and any company form completed by me. I authorize all previous employers or other persons who have knowledge of me or my records to release such information to Appalachian Underwriters, Inc or their agents. I herby release Appalachian Underwriters, Inc and any persons or companies that participate in or conduct a background inquiry regarding me from all claims or liabilities that may arise by such disclosures or such investigation.

While I understand that this application will be kept on file for a period of up to one year, I further understand that this application will be considered active for a period not to exceed ninety (90) days. I understand that if I wish to be considered for employment beyond this period, I should inquire as to whether or not applications are being accepted for the position for which I am interested and, if so, submit a new application. In connection with your application for employment and in keeping with Appalachian Underwriters, Inc.’s commitment to maintaining a safe, productive work environment at all facilities and work sites, agreement and cooperation with our Drug and Alcohol Testing Policy is required of all persons as a condition of employment by Appalachian Underwriters, Inc.

By clicking "Submit", you agree that all information on this application is true and accurate to the best of your knowledge, and that you are not applying on behalf of someone else.


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Appalachian Underwriters, Inc. considers all applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital or veteran status, or based on any individual’s status in any group or class protected by applicable federal, state, or local law. Appalachian Underwriters, Inc. also provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require an accommodation in the application process, please advise Management. This application must be completed in full before consideration for a position.

Please read and answer all questions carefully before submitting your application.

Fields in BOLD are required.