Behnke Insurance_23-0497-00_Employment Application

Position Applied for:

Application Date:

Date

Personal Information

Full Name:

First NameMiddle NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number:

Area CodePhone Number

Alternate Phone Number:

Area CodePhone Number

Email:

example@example.com

Social Security Number:

Are you available to work:

Full TimePart-Time

If you are under 18 years of age, can you provide required proof of work eligibility?

YesNo

Have you ever worked or submitted an application with this agency before?

YesNo

If yes, when?

Are you currently employed?

YesNo

May we contact your current employer?

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?

YesNo

If yes, attach explanation.

Browse Files

Do you have a reliable means of transportation?

YesNo

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

YesNo

If yes, attach explanation.

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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?

YesNo

If yes, attach copy to this application.

Browse Files

Employment (Start with most recent employment and work backwards)

Employment:

Education

Education

Licenses

P&C License

YesNo

State & License #

L&H License

YesNo

State & License #

Brokers License

YesNo

State & License #

Series 6 or 7 License

YesNo

State & License #

Other Licenses

Designations (Check all that apply)

Software (Check all that apply)

	Skill Level Low	Skill Level Medium	Skill Level High	Software Version
Microsoft Word
Microsoft Excel
Microsoft PowerPoint
Microsoft Outlook
APPLIED
AMS
Other (list software name under version):
Other (list software name under version):
Other (list software name under version):

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

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 signing)

It is Behnke Insurance Agencies, Inc.'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 Behnke Insurance Agencies, Inc. 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 Behnke Insurance Agencies, Inc. I understand that Behnke Insurance Agencies, Inc. retains the right to solely decide when such conflict exists.

If employed, I agree to hold in strictest confidence any information concerning Behnke Insurance Agencies, Inc., 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 Behnke Insurance Agencies, Inc., and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Behnke Insurance Agencies, Inc. or myself. I understand that no representative of Behnke Insurance Agencies, Inc., 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 Behnke Insurance Agencies, Inc..

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

Signature Name

First NameLast Name

Signature Date

Date

Please verify that you are human*