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Vspec Vehicle Claim Specialists EMPLOYMENT APPLICATION
We are an equal opportunity employer and do not discriminate in any aspect of employment on the basis of any protected status in accordance with the requirements of federal, state, and local law.
FOR MANAGERS USE ONLY
Starting Date:
Starting Pay:
Position:
Location:
Full Time Part Time Temporary Seasonal
DATE:
PERS
ONA
L
LAST NAME FIRST NAME MIDDLE INITIAL
ADDRESS CITY STATE ZIP CODE
EMAIL ADDRESS AREA CODE/TELEPHONE NO.
ARE YOU AT LEAST 18 YEARS OF AGE? HOW DID YOU LEARN OF THIS OPENING? ARE YOU WILLING TO WORK OVERTIME?
YES NO YES NO
HAVE YOU PREVIOUSLY WORKED WITH THIS COMPANY? ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?
YES NO YES NO
IF YES, WHEN? IF NO, PLEASE EXPLAIN.
PREF
EREN
CES
POSITION(S) APPLIED FOR Full Time Part Time
Temporary Seasonal
MAY WE CONTACT YOUR PRESENT EMPLOYER BEFORE YOUR EMPLOYMENT ENDS?
YES NO
DATE AVAILABLE FOR WORK STARTING PAY DESIRED
EDUC
ATIO
N
NAME OF INSTITUTION ATTENDED CITY AND STATE OF INSTITUTION SELECT LAST YEAR COMPLETED
SENIOR HIGH SCHOOL LOCATION DIPLOMA GPA 09
10
11
12
YES NO
COLLEGE LOCATION Type of Degree Major GPA 1 2 3 4
COLLEGE LOCATION Type of Degree Major GPA 1 2 3 4
OTHER LOCATION Type of Degree - Certificate GPA No. of Mos.
PROFESSIONAL CERTIFICATIONS OR DESIGNATIONS
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LIST BELOW ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT. EM
PLO
YMEN
T H
ISTO
RY
1 NAME, ADDRESS, AND
PHONE NUMBER OF EMPLOYER
FROM TO POSITION(S) HELD
DESCRIBE THE WORK YOU DID
STARTING PAY
REASON FOR LEAVING MO YR MO YR
LAST PAY NAME OF SUPERVISOR
(AREA CODE) TELEPHONE
2 NAME, ADDRESS, AND
PHONE NUMBER OF EMPLOYER
FROM TO POSITION(S) HELD
DESCRIBE THE WORK YOU DID
STARTING PAY
REASON FOR LEAVING MO YR MO YR
LAST PAY NAME OF SUPERVISOR
(AREA CODE) TELEPHONE
3 NAME, ADDRESS, AND
PHONE NUMBER OF EMPLOYER
FROM TO POSITION(S) HELD
DESCRIBE THE WORK YOU DID
STARTING PAY
REASON FOR LEAVING MO YR MO YR
LAST PAY NAME OF SUPERVISOR
(AREA CODE) TELEPHONE
4 NAME, ADDRESS, AND
PHONE NUMBER OF EMPLOYER
FROM TO POSITION(S) HELD
DESCRIBE THE WORK YOU DID
STARTING PAY
REASON FOR LEAVING MO YR MO YR
LAST PAY NAME OF SUPERVISOR
(AREA CODE) TELEPHONE
5 NAME, ADDRESS, AND
PHONE NUMBER OF EMPLOYER
FROM TO POSITION(S) HELD
DESCRIBE THE WORK YOU DID
STARTING PAY
REASON FOR LEAVING MO YR MO YR
LAST PAY NAME OF SUPERVISOR
(AREA CODE) TELEPHONE
6 NAME, ADDRESS, AND
PHONE NUMBER OF EMPLOYER
FROM TO POSITION(S) HELD
DESCRIBE THE WORK YOU DID
STARTING PAY
REASON FOR LEAVING MO YR MO YR
LAST PAY NAME OF SUPERVISOR
(AREA CODE) TELEPHONE
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PR
OFE
SSIO
NA
L RE
FER
ENC
ES
PROVIDE THE NAMES AND PHONE NUMBERS OF THREE FORMER EMPLOYERS OR INDIVIDUALS WHO CAN SPEAK OF YOUR WORK PERFORMANCE
NAME NAME NAME
ADDRESS ADDRESS ADDRESS
CITY, STATE, ZIP CITY, STATE, ZIP CITY, STATE, ZIP
TELEPHONE YEARS KNOWN TELEPHONE YEARS KNOWN TELEPHONE YEARS KNOWN
OCCUPATION OCCUPATION OCCUPATION
TRAI
NING
AND
EXP
ERIE
NCE
OTHER TRAINING AND EXPERIENCE
Describe any training, experience, or qualifications (not previously covered) that might be of interest to the company in considering your application.
SUPERVISORY EXPERIENCE
Have you ever supervised people? YES NO
If yes, explain nature of supervision:
AGRE
EMEN
T
APPLICANT’S STATEMENT
By signing below, I certify that the answers and information set out above are true, accurate and complete. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I authorize any person, organization, or company listed on this application to furnish the Company any and all information concerning my employment history, education, and qualifications for employment. I also authorize the Company to request and receive such information. I also acknowledge that any offer or acceptance of employment may be withdrawn, or if hired, my employment may be terminated, at any time, with or without cause, and with or without prior notice at my discretion or the discretion of the Company. I also understand that any offer of employment may be conditional upon my passing a post-offer physical examination including a drug screen administered by a health care professional selected by the Company, to which I hereby consent. This application will be retained by the Company for 90 days. After 90 days, if I wish to be considered for employment it will be necessary for me to complete another application. I understand and agree to all of the conditions and statements set forth above, and throughout this application.
Signature of Applicant Date
Printed Name