May 25, 2013

Online Employment Application

Applicant Instructions
Incomplete applications will not be processed. This application will be considered active for 180 days. Any applicant wishing to be considered beyond this time period should submit another application.

Please note. This application is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all questions completely and accurately. False or misleading statements on this form are grounds for terminating the application process, or, if discovered after employment, terminating employment. Additional testing of job-related skills or for the presence of illegal drugs in your body may be required prior to employment.
Applicant Information
First Name *
Middle Initial
Last Name *
Suffix
Address *
City *
ST *
Zip Code *
Home Telephone
Daytime Telephone
Email Address
Position Information
Which position are you interested in?
If you have a disability that impairs your ability to be considered, interviewed or tested for a position, please let us know what accommodations you may require.
How you were referred to this company, have you ever applied here before or been employed here before.
Are any of your friends or relatives employed by this company?
Desired Salary
Willing to relocate? Yes  No
Full-Time or Part-Time employment? Full-time  Part-time
If Part-Time, how many hours per week are you available?
What date are you available to start?
Are you at least 18 years of age? Yes  No
Citizenship Information
Are you prevented from being lawfully employed in this country due to a Visa or immigration status? Yes  No ?
Education Information
High School Name
City
ST
Receive High School Diploma? Yes  No
College/University
City
ST
How many years of College have you completed?
What is/was your course of study?
What was your graduation date/projected graduation date?
Please list all other Schooling:
Job Related Skills
List any languages other than English that you speak fluently:
Mark all skills that apply: Word Processing
10 Key Adding Machine
Typing WPM
List all knowledge of computer programs:
List any other skills:
List any licenses or certifications you have that you feel would be of value to this job or company
Security
Have you ever been bonded in prior employment? Yes  No
Have you ever been convicted of a misdemeanor or a felony? Yes  No If Yes, please explain
I have no objection to signing an employee agreement on confidential information. I consent to all medical examinations and drug and alcohol testing required by the Company, both during the selection process and throughout employment, if I am later hired. * Yes  No
Background Authorization
If I am interviewed and accept employment, I agree to allow company to investigate my background. Yes  No
Employment Experience
Please list your most recent employer first. Include any gaps in employment and state the reason for no employment during that period.
Employer
Address
City
ST
Zip Code
Phone
Job Title
Supervisor
Start Date
End Date
Starting Salary/Hourly Wage
Ending Salary/Hourly Wage
Reason for Leaving
Employer
Address
City
ST
Zip Code
Phone Number
Job Title
Supervisor
Start Date
End Date
Starting Salary/Hourly Wage
Ending Salary/Hourly Wage
Reason For Leaving
Employer
Address
City
ST
Zip Code
Phone Number
Job Title
Supervisor
Start Date
End Date
Starting Salary/Hourly Wage
Ending Salary/Hourly Wage
Reason for Leaving
References
Include only individuals familiar with your work ability. Do not include relatives. Please do not include individuals to whom you directly reported in the last five years.
  Name, Address, Phone: # Years Known Relationship
1.
2.
3.
Authorization and Understanding
I understand and agree that employment with the Company is at will and that either I or the Company can terminate my employment and compensation, with or without cause, and with or without notice, at any time. I acknowledge that no representations, either oral or written, have been made to me to the contrary and that pre-existing understandings which contradict an at will status of employment are canceled. Further, I understand that only the Chief Executive Officer has any authority to enter into any agreement for employment for any fixed period of time, or make any agreement contrary to the foregoing and that any such agreement must be in writing and signed by the Chief Executive Officer and me. In consideration of my employment, I agree to conform to the rules and policies of the Company.
* = Required Field
I hereby certify that I have a genuine interest in being hired and that all of the foregoing statements are true and correct. I agree to assume a continuing responsibility to disclose additional or new information, called for by this Employment Application, but known to me only after this Application was completed, and understand that my failure to make such a disclosure, and that falsification of any of the information given herein, on any employment form or in any interview, are grounds for immediate termination, regardless of when such failure or falsification may be discovered.

I also understand that my employment may be terminated at any time, with or without cause, without liability to me for salary, wages, or other benefits except as may have been earned up to date of the termination of services.
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© 2013 All Rights Reserved BKC Insurance 220 Water St. Cheboygan , MI 49721
Phone (231) 627-4381
Toll Free (800) 382-2766
Fax (231) 627-5171
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