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Application for Employment


(WE ARE AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER)

APPLICANT'S STATEMENT

I understand that the Company is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, disability, or any other category protected by federal, state, or local law.

I authorize former and present employers, work and personal references listed in the application, and any other individuals, any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release such parties from all liability for any damages that may result from furnishing same to the Company. I also authorize the Company to provide truthful information concerning my employment with it to future employers and I agree to hold it harmless for providing such information.

I understand that the Company reserves the right, to the extent permitted by law, to require drug or alcohol screening tests of an applicant or an employee either prior to employment or any time during employment and I hereby give my consent to any such tests. I consent to the release of the results of any such tests to the Company or its designee. I release the Company and its designee from any and all liability and damages which may result or arise from any drug test or the provision of information in connection with such a test.

I understand that this employment application and any other Company documents are not promises of employment. Should I be employed, I understand that my employment will be on a trial period for ninety days from the date of my hiring, and that I will remain an at-will employee thereafter. I further understand that, if I am employed, I can terminate my employment at any time with or without cause and with or without advance notice, and that the Company has a similar right. I understand that no manager, representative, or agent of the Company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, except that the Company President may do so in writing.

I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form.

The information given by me on this application and during the interview process is true and complete in all respects, and I agree that if the information is found to be false, misleading or unsatisfactory in any respect (in the Company's judgment) that I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired.

I authorize the Company to conduct electronic inquiry related to my background, including review of all social networking sites and to make adverse decisions as a result of such inquiries. I further understand that the term “investigative consumer report” means a report in which information on my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with my neighbors, friends, or associates, or with others with whom I am acquainted or who may have knowledge concerning any such items of information.

I CERTIFY THAT I HAVE RECEIVED A SEPARATE WRITTEN NOTIFICATION THAT THE COMPANY MAY OBTAIN A CONSUMER REPORT ON ME FOR USE IN CONNECTION WITH MY APPLICATION AND, IF I AM HIRED, MY EMPLOYMENT WITH THE COMPANY. I AUTHORIZE THE COMPANY TO OBTAIN THIS REPORT.

THIS APPLICATION WILL BE CONSIDERED “ACTIVE” FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

Each inquiry on this application must be fully answered or completed. Otherwise, you will not be considered for employment.



PERSONAL DATA
First Name
Required
Middle Name
Required
Last Name
Required
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
How long have you lived there?
Required
Previous Street Address
Optional
City, State. ZIP Code
Optional
How long did you live there?
Optional
Primary Phone Number
Required
E-Mail Address
Required
Are you 18 years of age or older?
Required

Position Desired
Required
Placement Desired
Required


When are you available for work?
Required
/ /
Career Objectives
Required
PREVIOUS EMPLOYMENT
Please list the names of your present or previous employers in chronological order with present or last employer listed first. Include part-time and seasonal employment.
If self-employed, give firm name and supply business references. DO NOT ANSWER “SEE RESUME.” Fill out this form completely.
Employer
Required
Dates Employed (From - To)
Required
Telephone Number(s)
Required
Address
Required
Job Title
Required
Supervisor Name & Title
Required
Hourly Rate/Salary - Starting & Final
Required
Work Performed
Required
Reason for Leaving
Required
Employer
Required
Dates Employed (From - To)
Required
Telephone Number(s)
Required
Address
Required
Job Title
Required
Supervisor Name & Title
Required
Hourly Rate/Salary - Starting & Final
Required
Work Performed
Required
Reason for Leaving
Required
Employer
Required
Dates Employed (From - To)
Required
Telephone Number(s)
Required
Address
Required
Job Title
Required
Supervisor Name & Title
Required
Hourly Rate/Salary - Starting & Final
Required
Work Performed
Required
Reason for Leaving
Required
BACKGROUND INFORMATION
Please explain fully any gaps in your employment history. Be sure to account for all periods of time including military service and any period of unemployment.
List any other names which you may have used and which will be necessary to verify your prior employment
Required
If hired, can you provide proof that you are legally entitled to work in the U.S.?
Required

If not, what steps must be taken for you to begin employment lawfully?
Optional
Have you ever been terminated or asked to resign from any job?
Required

If yes, please explain circumstances
Optional
May we contact your current employer?
Required

If no, please explain
Optional
Have you ever worked for this Company?
Required

If yes, please give dates and position
Optional
Do you have any friends or relatives working here or for one of our other companies?
Required

If yes, name(s), relationship and company
Optional
How were you referred to us?
Required
Have you ever plead no contest, nolo contendre, or been convicted of a crime?
Required

Are any charges currently pending against you?
Required

Has any adjudication ever been withheld?
Required

(NOTE: Answering “yes” to these questions does not constitute an automatic bar to employment). If you answered yes to any of the preceding questions, please give dates and details
Optional
Amount of overnight travel acceptable to you
Required
Do you have any commitments to any other employer which may affect your employment?
Required

If yes, please explain circumstances
Optional
EDUCATION
Name of High School
Required
Years Completed
Required
Diploma/Degree
Required
Describe Course of Study or Major
Required
Describe Specialized Experience, Training,Skills, and Extra-Curricular Activities
Required
Name of College/University
Required
Years Completed
Required
Diploma/Degree
Required
Describe Course of Study or Major
Required
Describe Specialized Experience, Training,Skills, and Extra-Curricular Activities
Required
Name of Graduate/Professional School
Required
Years Completed
Required
Diploma/Degree
Required
Describe Course of Study or Major
Required
Describe Specialized Experience, Training,Skills, and Extra-Curricular Activities
Required
Name of Trade or Correspondence School
Required
Years Completed
Required
Diploma/Degree
Required
Describe Course of Study or Major
Required
Describe Specialized Experience, Training,Skills, and Extra-Curricular Activities
Required
RELEVANT EXPERIENCE
Please indicate positions you have held in prior jobs
Management/Supervision
Optional




Office/Administrative
Optional





Sales/Marketing
Optional




If you selected Other, please explain
Optional
List any professional designations, certifications, licenses, or courses that may be applicable to the position for which you are applying
Optional
OTHER INFORMATION
Please describe any other experience that you have which would be relevant to the job for which you are applying
Optional
PERSONAL REFERENCES
Please provide three personal references. Do NOT USE past employers and/or relatives
Name
Required
Address
Required
Telephone Number(s)
Required
Occupation
Required
Name
Required
Address
Required
Telephone Number(s)
Required
Occupation
Required
Name
Required
Address
Required
Telephone Number(s)
Required
Occupation
Required
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Valdosta Insurance Services, Inc.
812 Northwood Park Drive l Post Office Box 2070
Valdosta, GA 31604-2070 l 
Phone: (229) 242-4560 l Phone: (888) 242-4560 l Fax: (229) 242-4561 
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