Job Application

Name(Required)

First Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Phone(Required)

Are you 18 years of age or older?(Required)

Yes

No

Are you either a U.S. citizen or an alien authorized to work in the U.S.?(Required)

Yes

No

Have you ever worked or attended school under another name? If so, under what name?(Required)

Education

High School:(Required)

Graduated?(Required)

Yes

No

Course of Study:

Technical School:

Graduated?

Yes

No

Course of Study:

College/University:

Graduated?

Yes

No

Course of Study:

Post-Graduate Education:

Graduated?

Yes

No

Course of Study:

Other education, training or special skills:

Certifications (list certifications)

Certifications

Work Experience

Please list all previous employment, beginning with the most recent.

Upload Resume/CV(Required)

Max. file size: 50 MB.

Employer #1:(Required)

Employer Address:(Required)

Street Address Address Line 2 City State ZIP / Postal Code

From:(Required)

To:(Required)

Position Held:(Required)

Reason for Leaving:(Required)

Supervisor's Name & Title:(Required)

May we contact?(Required)

Yes

No

Description of Duties:(Required)

Employer #2:

Employer Address:

Street Address Address Line 2 City State ZIP / Postal Code

From:

To:

Position Held:

Reason for Leaving:

Supervisor's Name & Title:

May we contact?

Yes

No

Description of Duties:

Employer #3:

Employer Address:

Street Address Address Line 2 City State ZIP / Postal Code

From:

To:

Position Held:

Reason for Leaving:

Supervisor's Name & Title:

May we contact?

Yes

No

Description of Duties:

Employer #4:

Employer Address:

Street Address Address Line 2 City State ZIP / Postal Code

From:

To:

Position Held:

Reason for Leaving:

Supervisor's Name & Title:

May we contact?

Yes

No

Description of Duties:

References

Identify three persons we may contact who know your work, beginning with the most recent.

Reference #1 Name:(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Position or Title:(Required)

Years Known(Required)

Please enter a number from 0 to 100.

Reference #2 Name:(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Position or Title:(Required)

Years Known(Required)

Please enter a number from 0 to 100.

Reference #3 Name:(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Position or Title:(Required)

Years Known(Required)

Please enter a number from 0 to 100.

Authorization and Acknowledgements

I certify that all information I have provided in order to apply for and secure work with Stumm Insurance, LLC. is true, complete and correct. I understand that my information provided by me that is found to be false, incomplete or misrepresented in my respect will be sufficient cause to (I) cancel further consideration of this application, or (II) immediately discharge me from the employer’s service, whenever it is discovered. I understand that if I am hired my employment shall be considered “at will” and may be terminated by this company at any time without liability for wages or salary except for such as may have been earned at the date of such termination unless or until superseded by specific written employment contract. I also understand that nothing in this application should be considered as an offer of employment by Stumm Insurance, LLC. I acknowledge that if I need reasonable accommodation in either the application process or employment, I should bring it to attention of the interviewer or Human Resources Department. I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

Date(Required)

Apply to Stumm Insurance

Position Desired

Education

Certifications (list certifications)

Work Experience

References

Authorization and Acknowledgements

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