Basic Employment Application Form

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Image Field
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Employment Application We are an equal opportunity employer. Applicants will be considered regardless of race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status. Equal access to the hiring process, services, and employment is available to all individuals. Applicants requiring accommodations to the application and/or interview process should contact the Human Resource Representative.

Each question should be answered completely and accurately. No action will be taken on this application until all questions have been answered and the application has been signed and dated. Verification of eligibility to work in the U.S. will be required if an employment offer is made.
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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E-mail* This field is required.
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Position(s) applying for* This field is required.
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We are looking for commissioned insurance agents. Are you a licensed health/ accident/ life agent in LA?
Yes
No
I am currently applying to become licensed.
No, but I am interested in become a licensed agent
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Wage expectations* This field is required.
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Salary or Hourly?* This field is required.
Salary
Please Select
Salary
Hourly
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Referral source
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Are you over the age of 18?* This field is required.
YES
NO
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Are you eligible to work in the United States?* This field is required.
YES
NO
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Are you fluent in a foreign language?* This field is required.
YES
NO
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If yes, what language(s)?* This field is required.
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Are you currently employed?* This field is required.
YES
NO
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Date available for work* This field is required.
Date
Month
Day
Year
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Are you available to work?* This field is required.Check all that apply
Full time
Part time
Shift work
Temporary
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Have you applied here before?* This field is required.
YES
NO
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If yes, give date:* This field is required.
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Have you been convicted of a felony/misdemeanor (other than traffic violations)?* This field is required.
YES
NO
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If so, provide the location, date and result/outcome for each conviction:* This field is required.Conviction, city & state, outcome
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EDUCATION
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Highest level of education completed:* This field is required.
Please Select
Please Select
High School / GED
Trade School
College
Graduate
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Please complete the appropriate sectionsComplete all of the fields that apply for your education background.
Name & Location of School
Number of Years Attended
Did You Graduate?
Degree or Certification
GED / High School
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Trade School
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
College
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Graduate
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
GED / High School
Trade School
College
Graduate
Name & Location of School
Row 0, Column 0
Number of Years Attended
Row 0, Column 1
Did You Graduate?
Row 0, Column 2
Degree or Certification
Row 0, Column 3
Name & Location of School
Row 1, Column 0
Number of Years Attended
Row 1, Column 1
Did You Graduate?
Row 1, Column 2
Degree or Certification
Row 1, Column 3
Name & Location of School
Row 2, Column 0
Number of Years Attended
Row 2, Column 1
Did You Graduate?
Row 2, Column 2
Degree or Certification
Row 2, Column 3
Name & Location of School
Row 3, Column 0
Number of Years Attended
Row 3, Column 1
Did You Graduate?
Row 3, Column 2
Degree or Certification
Row 3, Column 3
1 of 4
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WORK HISTORY Please list your four most recent employers, list the most recent first
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1. Employer
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Employer's Name (Most current)* This field is required.
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Address & location of business* This field is required.
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Your title* This field is required.
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May we contact this employer?* This field is required.
YES
NO
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Supervisor's name* This field is required.
First and Last Name
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Phone number* This field is required.
Area Code
Phone Number
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Start date* This field is required.
Month
Day
Year
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End date
Month
Day
Year
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Wages START:* This field is required.
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Salary or Hourly* This field is required.
Please Select
Please Select
Salary
Hourly
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Wages END:
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Salary or Hourly* This field is required.
Please Select
Please Select
Salary
Hourly
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check the box if you are still employed with your first employer
Still Employed
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Work performed:* This field is required.
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Reason for leaving* This field is required.Put the reason you are looking to leave if still employed.
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2. Employer
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Employer's Name (Second most recent)
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Address & location of business
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Your title
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May we contact this employer?
YES
NO
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Supervisor's name
First and Last Name
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Phone number
Area Code
Phone Number
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Start date
Month
Day
Year
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End date
Month
Day
Year
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Wages START:
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Salary or Hourly
Please Select
Please Select
Salary
Hourly
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Wages END:
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Salary or Hourly
Please Select
Please Select
Salary
Hourly
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Work performed:
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Reason for leaving
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3. Employer
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Employer's Name (Third most recent)
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Address & location of business
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Your title
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May we contact this employer?
YES
NO
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Supervisor's name
First and Last Name
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Phone number
Area Code
Phone Number
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Start date
Month
Day
Year
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End date
Month
Day
Year
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Wages START:
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Salary or Hourly
Please Select
Please Select
Salary
Hourly
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Wages END:
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Salary or Hourly
Please Select
Please Select
Salary
Hourly
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Work performed:
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Reason for leaving
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4. Employer
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Employer's Name (Fourth most recent)
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Address & location of business
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Your title
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May we contact this employer?
YES
NO
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Supervisor's name
First and Last Name
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Phone number
Area Code
Phone Number
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Start date
Month
Day
Year
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End date
Month
Day
Year
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Wages START:
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Salary or Hourly
Salary
Please Select
Salary
Hourly
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Wages END:
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Salary or Hourly
Please Select
Please Select
Salary
Hourly
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Work performed:
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Reason for leaving
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ADDITIONAL INFORMATION
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Do you have a U.S. military service record?* This field is required.
YES
NO
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Click to edit
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If yes, branch of service
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Discharge date and rank
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List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)
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List any additional information you would like us to consider:
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REFERENCES List three professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.
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1. Full Name* This field is required.
First Name
Last Name
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Company* This field is required.
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Best phone number to reach them* This field is required.
Area Code
Phone Number
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Years acquainted* This field is required.
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Relationship* This field is required.
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2. Full Name* This field is required.
First Name
Last Name
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Company* This field is required.
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Best phone number to reach them* This field is required.
Area Code
Phone Number
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Years acquainted* This field is required.
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Relationship* This field is required.
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3. Full Name* This field is required.
First Name
Last Name
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Company* This field is required.
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Best phone number to reach them* This field is required.
Area Code
Phone Number
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Years acquainted* This field is required.
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Relationship* This field is required.
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AUTHORIZATION I understand that R.J. BLANCHARD BENEFIT SERVICES, LLC is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination if employed.

I authorize RJ BLANCHARD BENEFIT SERVICES, LLC to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, criminal history, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to RJ BLANCHARD BENEFIT SERVICES, LLC.

I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks). Testing may be applicant or employer paid based on the employer.

I further agree to submit to RJ BLANCHARD BENEFIT SERVICES, LLC, a colored copy of your valid driver's license and signed social security card if you are offered a position. This is required to complete your background investigation and to verify your insurance license (if you are licensed).

I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made. I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from RJ BLANCHARD BENEFIT SERVICES, LLC and still wish to be considered for employment, it will be necessary to complete a new application.

I understand that if hired, employment is at will, regardless of the employer, and may be terminated by myself, the employer, or RJ BLANCHARD BENEFIT SERVICES, LLC at any time, with or without cause or notice, for any reason or no reason.
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By entering your name, you agree to accept the terms of the above document with an electronic signature.* This field is required.
I agree
I do not agree
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You must agree to accept the terms of the document in order to submit an application.
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Type signature* This field is required.
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Signature:
Clear
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Date* This field is required.
Date
Month
Day
Year
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Upload your resume, click Choose File
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Upload a cover letter, click Choose File
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