Career Opportunities

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alternate Phone Number *

Social Security Number: *

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? *

Are you currently employed? *

May we contact your current employer? *

Do you have a reliable means of transportation? *

Have you ever been convicted of a crime, excluding misdemeanors? *

(If yes, attach explanation.) *

Have you ever been discharged from any employment or been asked to resign? *

(If yes, attach 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.) *

Max file size: 20MB

Employment

(Start with most recent employment and work backwards)

Employer 1 *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor’s Name & Title *

Employment Start Date *

Employment End Date *

Ending Compensation *

Reason for Leaving *

Describe work performed *

Employer 2 *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor’s Name & Title *

Employment Start Date *

Employment End Date *

Ending Compensation *

Reason for Leaving *

Describe work performed *

Employer 3 *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor’s Name & Title *

Employment Start Date *

Employment End Date *

Ending Compensation *

Reason for Leaving *

Describe work performed *

Education

Name of School 1 *

Address of School *

Line 1

Line 2

City

State

Zip Code

Country

Grade Completed or Degree(s) *

Subjects Studied *

Name of School 2 *

Address of School *

Line 1

Line 2

City

State

Zip Code

Country

Grade Completed or Degree(s) *

Subjects Studied *

Name of School 3 *

Address of School *

Line 1

Line 2

City

State

Zip Code

Country

Grade Completed or Degree(s) *

Subjects Studied *

Licenses

Software:

References

(Please include at least two business and one personal references.)

Reference 1

Name *

First

Last

Company Name *

Phone Number *

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Reference 2

Name *

First

Last

Company Name *

Phone Number *

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Reference 3

Name *

First

Last

Company Name *

Phone Number *

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Reference 4

Name *

First

Last

Company Name *

Phone Number *

Relationship *

Notification and Agreement (Please read before signing)

It is Burns Insurance Agency LLC 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 Burns Insurance Agency LLC from all liability that might result from making an investigation.

I understand that completion of this employment application does not guarantee that I have been employed by Burns Insurance Agency LLC .

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.

Career Opportunities

Career Opportunities in Our Company

Open Positions:

Burns Insurance Employment Application Form

Personal Information

Employment

Education

Licenses

Designations

Software:

References

Notification and Agreement (Please read before signing)

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