Coronet Job Application Form

Full Name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

What position are you applying for?

Are you able to work Part-Time or Full-Time?

Available start date:*

MonthDayYear

What is your current employment status?*

EmployedUnemployedSelf-EmployedStudent

May we contact your current/former employee for reference?*

YesNo

Are you eligible to work in the United States? (Proof of eligibility will be required upon employment)*

YesNo

Have you ever been convicted of a crime, excluding misdemeanors? (If yes, attach explanation.)*

YesNo

Do you have a reliable means of transportation?*

YesNo

Have you ever been discharged from any employment or been asked to resign?(If yes, complete explanation below.)*

YesNo

Discharge 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.)*

YesNo

Binding Agreement(s)

Browse Files

Resume Attachment

Browse Files

Please attach resume if you have one available.

Employer 1 Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor's Name & Title

Employment Start Date

Date

Employment End Date

Date

Ending Compensation

Please note annual or hourly amount

Reason for Leaving

Describe Work Performed

Employer 2 Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor's Name & Title

Employment Start Date

Date

Employment End Date

Date

Ending Compensation

Please note annual or hourly amount

Reason for Leaving

Describe Work Performed

Employer 3 Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor's Name & Title

Employment Start Date

Date

Employment End Date

Date

Ending Compensation

Please note annual or hourly amount

Reason for Leaving

Describe Work Performed

Name of School 1

School Location

City/State

Grade Completed or Degree(s)

Subjects Studied

Name of School 2

School Location

City/State

Grade Completed or Degree(s)

City/State

Subjects Studied

City/State

FL 220 License*

YesNo

License Number

Expiration Date

Date

FL 440 License*

YesNo

License Number

Expiration Date

Date

Other Licenses

Please describe

Designations (Check all that apply)

Microsoft Word*

LowMediumHigh

Microsoft Excel*

LowMediumHigh

Microsoft PowerPoint*

LowMediumHigh

Microsoft Outlook*

LowMediumHigh

EZLynx*

LowMediumHigh

Other

Relationship Type 1*

Name*

First NameLast Name

Company Name

If business reference.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Occupation

Relationship Type 2

Name

First NameLast Name

Company Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Occupation

Relationship Type 3

Name

First NameLast Name

Company Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Occupation

Relationship Type 4

Name

First NameLast Name

Company Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Occupation

Additional Experience or Qualifications

List any other experience, skills or qualifications that you believe should be considered in evaluating your qualifications for employment

It is the policy of Coronet Insurance Agency, LLC 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 Coronet Insurance Agency, LLC 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 Coronet Insurance Agency, LLC. I understand that Coronet Insurance Agency, LLC retains the right to solely decide when such conflict exists. If employed, I agree to hold in strictest confidence any information concerning Coronet Insurance Agency, LLC, 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 Coronet Insurance Agency, LLC, and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Coronet Insurance Agency, LLC or myself. I understand that no representative of Coronet Insurance Agency, LLC, 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 Coronet 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.

Signature*

First NameLast Name

Employment Application

Personal Information

Employment

Education

Licenses

Applications

References

Notification and Agreement