Highstreet Insurance & Financial Services Employment Application

1

Applying for Position* This field is required.

2

Full Name* This field is required.

First Name

Middle Name

Last Name

3

Current Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

4

Email Address* This field is required.

johndoe@example.com

5

Phone Number* This field is required.

Area Code

Phone Number

6

Are you 18 years of age or older?* This field is required.

YESNO

7

If you are under 18 years of age, can you provide required proof of your eligibility to work?* This field is required.

YESNO

8

Have you ever filed an application with us before? * This field is required.

YESNO

9

When did you last apply to work with us?* This field is required.

Date

10

Have you ever been employed with us before? * This field is required.

YESNO

11

When were you previously employed with us?* This field is required.

Date

12

Do any of your friends or relatives, other than spouse, work here? * This field is required.

YESNO

13

Are you currently employed?* This field is required.

YESNO

14

If you are currently employed, may we contact your current employer?* This field is required.

YESNO

15

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?* This field is required.Proof of citizenship or immigration status will be required upon employment.

YESNO

16

What date are you available to start work?* This field is required.

Date

17

Are you available to work full-time? * This field is required.

YESNO

18

If no, please describe your desired work schedule. * This field is required.

19

What is your desired salary range?* This field is required.

20

Are you currently on lay-off status and subject to recall?* This field is required.

YESNO

21

Can you travel if the job requires it?* This field is required.

YESNO

22

What is the highest level of education completed?* This field is required.

High School

Undergraduate College

Graduate School

Other

23

Education History* This field is required.Please enter the details for the High School you attended.

Name of School

Address

City, State, Zip

Diploma / Degree

24

Education History* This field is required.Please enter the details for the Undergraduate College or University you attended.

Name of School

Address

City, State, Zip

Course of Study

Degree

25

Education History* This field is required.Please enter the details for the Graduate school you attended.

Name of School

Address

City, State, Zip

Course of Study

Degree

26

If other, please explain. * This field is required.

27

Employment History* This field is required.Start with your present or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status. Please provide at least 10 years of employment history if applicable.

Employer

Job Title

Address, City, State, Zip Code

Phone Number

Start Date - End Date

Hourly Rate / Salary

Supervisor Name

Reason for Leaving

28

Employment History* This field is required.Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer

Job Title

Address, City, State, Zip Code

Phone Number

Start Date - End Date

Hourly Rate / Salary

Supervisor Name

Reason for Leaving

29

Employment History* This field is required.Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer

Job Title

Address, City, State, Zip Code

Phone Number

Start Date - End Date

Hourly Rate / Salary

Supervisor Name

Reason for Leaving

30

Employment History* This field is required.Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer

Job Title

Address, City, State, Zip Code

Phone Number

Start Date - End Date

Hourly Rate / Salary

Supervisor Name

Reason for Leaving

31

Employment History* This field is required.Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer

Job Title

Address, City, State, Zip Code

Phone Number

Start Date - End Date

Hourly Rate / Salary

Supervisor Name

Reason for Leaving

32

Employment History* This field is required.Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer

Job Title

Address, City, State, Zip Code

Phone Number

Start Date - End Date

Hourly Rate / Salary

Supervisor Name

Reason for Leaving

33

Describe any specialized training, apprenticeships, skills, and extra-curricular activities.* This field is required.

34

List professional, trade, business or civic activities and offices held.You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

35

Please share any additional information you feel may be helpful to us in considering your application.

36

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?

YESNO

37

Reference #1 - Do not list relatives.* This field is required.

Name

Phone

Title (if applicable)

Company (if applicable)

Address

Relationship

38

Reference #2 - Do not list relatives.* This field is required.

Name

Phone

Title (if applicable)

Company (if applicable)

Address

Relationship

39

Reference #3 - Do not list relatives.* This field is required.

Name

Phone

Title (if applicable)

Company (if applicable)

Address

Relationship

40

How did you hear about this position?* This field is required.

Online Search (i.e. Indeed)

Social Media (i.e. Facebook, LinkedIn)

Career Fair

Chamber of Commerce

Referral

Other

41

If you were referred, by who?* This field is required.

42

Upload Resume

Drag and drop files here

Select files to upload

Max. file size: 10.0MB

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Applicant's Statement: I certify that answers given herein are true and complete. I authorized investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.* This field is required.

Clear

44

Please verify that you are human* This field is required.

45

This is a fill in the blanks field. Please add appropriate blank fields and text.