Blackwood Insurance Group, PA Employment Application
Date of Application: *
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Personal Information
My work availability is: *
Have you ever worked or submitted an application with this agency before? *
Are you currently employed? *
May we contact your current employer? *
Are you eligible to work in the United States? (Proof of eligibility will be required upon employment.) *
Have you ever been convicted of a crime, excluding minor traffic violations? *
If above is yes, please explain (required if above is yes):
Do you have a reliable means of transportation? *
Have you ever been discharged from any employment or been asked to resign? (If yes, explain below:) *
If above is yes, please explain (required if above is yes):
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? *
Employment
Start with MOST RECENT employment and then work backwards. There will be an opportunity to explain gaps in employment, as well.
Current / Most Recent Employment
Information about my Current or Most Recent Employment:
Employment START Date *
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Employment END Date *
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Describe the work you performed: *
Next Most Recent Employment
Employment START Date *
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Employment END Date *
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Describe the work you performed: *
Next Most Recent Employment
Employment START Date *
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Employment END Date *
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Describe the work you performed: *
Education
High School
Highest Grade Completed *
Start with your MOST RECENT college first, then work backwards from there.
Most Recent College
Next Most Recent College
Next Most Recent College
Insurance Licenses
Do you have a P&C License? *
Do you have a L&H License? *
References
Please include at least two business and one personal reference.
Reference 1
Reference 2
Reference 3
Additional Information
List any other experience, skills or qualifications that you believe should be considered in evaluating your qualifications for employment.
Do you have a resume'? *
It is Blackwood Insurance Group, PA's policy to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national original, 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 statement and information contained in this application. I release from liability anyone supplying such information and I also release Blackwood Insurance Group, PA 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 Blackwood Insurance Group, PA. I understand that Blackwood Insurance Group, PA retains the right to solely decide when such conflict occurs.
If employed, I agree to hold in strictest confidence any information concerning Blackwood Insurance Group, PA, its Insureds, its Prospects and its Carriers that may come to my knowledge.
In consideration of my employment, if I am employed, I agree to the employment policies of Blackwood Insurance Group, PA, and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Blackwood Insurance Group, PA or myself. I understand that the completion of this employment application does not constitute an offer of employment, nor guarantee that I will be employed by Blackwood Insurance Group, PA.
I certify that all answers given by me are true, accurate and complete, I understand that the falsification, misrepresentations 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.
Affirmation *
Date *
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