Hiring form - Office Manager - Veronica's Insurance | Auto Insurance

Applicant Information
Name*
First Middle Last
Date of birth*
MM slash DD slash YYYY
Address*
Street Address Apartment/Unit # City State ZIP
Phone*
Ex.: 9097915564 (No dashes, no spaces)
Email address*
Are you authorized to work in the U.S.?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
If so, when?
Do you have any friends or relatives working here?*
- Yes
- No
If yes, please, complete:
Name Relationship
Have you ever used another name?*
- Yes
- No
If yes, please, complete:
Name Reason

Previous Employment
Please list the names of your present or previous employers in chronological order with present or last employer listed first. If self-employed, give firm name and supply business references.
Company*
Phone*
Ex.: 9097915564 (No dashes, no spaces)
Address*
Supervisor*
Job Title*
Responsibilities*
From*
To*
Reason for leaving*
May we contact your previous supervisor for a reference?*
- Yes
- No

Second Previous Employment
Company*
Phone*
Ex.: 9097915564 (No dashes, no spaces)
Address*
Supervisor*
Job Title*
Responsibilities*
From*
To*
Reason for leaving*
May we contact your previous supervisor for a reference?*
- Yes
- No

Resume
Upload you resume*
Accepted file types: pdf, doc, docx, Max. file size: 3 MB.

Disclaimer and Signature
I understand that any misrepresentation, falsification or material omission of information may result in my failure to receive an offer, or if I have been hired, in my dismissal from employment. Continuation of employment is contingent upon a clear criminal background check. In consideration of my employment, I agree to confirm to the rules and standards of Veronica's Insurance Services, Inc. and time, either at my option or at the option of the company. This employment at will relationship exists regardless of any other written statements or policies contained in any Company documents or any verbal statement to the contrary.*
I agree
I understand that any misrepresentation, falsification or material omission of information may result in my failure to receive an offer, or if I have been hired, in my dismissal from employment. Continuation of employment is contingent upon a clear criminal background check. In consideration of my employment, I agree to confirm to the rules and standards of Veronica's Insurance Services, Inc. and time, either at my option or at the option of the company.
This employment at will relationship exists regardless of any other written statements or policies contained in any Company documents or any verbal statement to the contrary.
Signature*
Date*
MM slash DD slash YYYY

Applicant's Statement and Agreement
In the event of my employment with Veronica’s Insurance Services, Inc., I will comply with all rules and regulations of Veronica’s Insurance Services, Inc. (“Employer”). I understand that Employer reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination and a test for the presence of alcohol in my system, performed by a doctor selected by Employer. Further, I understand that at any time after I am hired, Employer may require me to submit to a physical examination and an alcohol test, to the extent permitted by law. I consent to the disclosure of the results of any physical examination and related tests to Employer. I also understand that I may be required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed. I understand that Employer may contact my previous employers and I authorize those employers to disclose to Employer all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to Employer, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide Employer with any pertinent information they may have regarding me. I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed by Employer and any such information is later found to be false or incomplete in any respect, I may be dismissed. If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and compensation may be terminated by Employer at any time and for any reason whatsoever, with or without good cause at the option of either Employer or myself. No implied, oral, or written agreements contrary to the express language of this agreement are valid unless they are in writing signed by the Chief Executive Officer of Employer, or another individual who has any authority to make any agreements contrary to the foregoing. This agreement is the entire agreement between Employer and the undersigned regarding the rights of Employer and the undersigned to terminate employment with or without good cause, and this agreement takes the place of all prior and contemporaneous agreements, representations, and understandings of the undersigned and Employer. I hereby acknowledge that I have read the above statements and understand the same. If you have any questions regarding these statements, please ask an Employer representative before signing. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS AND AGREEMENT.
Signature*
Date*
MM slash DD slash YYYY

Employment Application

Step 1 of 8

Applicant Information

Previous Employment

Second Previous Employment

Education

Resume

Disclaimer and Signature

Applicant's Statement and Agreement