PERSONAL INFORMATION

Legal Full Name

Social Security Number

Present Address (include City, State, and Zip)

Email Address

FAX #

Cell Phone

Day Phone

Night Phone

Legal right to work in the USA?
Yes No

If you are under 18, what is your date of birth?

Position Desired

Salary Desired

Full or Part Time?
Full Time Part Time

Days/Hours Available?


How were you informed of opportunities at our company?
Newspaper Employee Referral  Agency Other
(explain)

Have you previously worked for our company?
No Yes (explain)

Do you have any relatives employed at our company?
If yes, give name, relationship, and location.
No Yes(explain)

Do you have any acquaintance employed at our company?
If yes, give name, relationship, and location.
No Yes(explain)

When will you be available for work?


If necessary will you travel?
No Yes

If necessary will you relocate?
No Yes

For reference purposes only, do you use any other names?
If so, please explain.
No Yes(explain)

Have you been convicted of a crime in the past five years?
If yes, please explain.
No Yes(explain)

(NOTE: A conviction will not necessarily bar you from
employment, but will be judged on its merits with respect to
time, circumstances and seriousness as it relates to
employment considerations.)

EDUCATION

High School Name

Highest Level Completed:

Did you graduate (Yes or No)?
No Yes
Grade Point Average:

Higher Education School Name

Highest Level Completed

Did you graduate (Yes or No)?
No Yes
Grade Point Average

EMPLOYMENT HISTORY


PRESENT OR MOST RECENT POSITION (1)

From (Mo/Yr) to (Mo/Yr)

Position Title

Beginning Salary

Ending Salary

Company Name

Type of Business?

Business Phone Number

Business Address

Describe your duties

Name of last supervisor

Reason for Leaving?

May we contact for reference purposes (Yes or No)?
Yes No(explain)

PRIOR POSITION (2)

From (Mo/Yr) to (Mo/Yr)

Position Title

Beginning Salary

Ending Salary

Company Name

Type of Business?

Business Phone Number

Business Address

Describe your duties

Name of last supervisor

Reason for Leaving?

May we contact for reference purposes (Yes or No)?
Yes No(explain)

PRIOR POSITION (3)

From (Mo/Yr) to (Mo/Yr)

Position Title

Beginning Salary

Ending Salary

Company Name

Type of Business?

Business Phone Number

Business Address

Describe your duties

Name of last supervisor

Reason for Leaving?

May we contact for reference purposes (Yes or No)?
Yes No(explain)

EXPERIENCE/SKILLS

Which of the following items do you have experience with?
Adding Machine Calculator Data Entry Drafting
Filing Scheduling Telephone Switchboard
Shorthand (words per minute)
Typing/Keyboard (words per minute)

How will your experience in these areas help our company?


Personal Computer knowledge experience:
(specify name, type, etc. more detail is better!)

Word Processing:

Spreadsheet Software:

Database Software:

Graphics Software:

Desktop Publishing:

Other:

JOB EXPERIENCE

Describe applicable customer service experience (including
number of years' experience)

Describe policy administration/formulation experience
(including number of years' experience)

Describe program initiation or development experience
(including number of years' experience)

Describe types of technical/professional projects in which
you were involved in prior positions (including number of
years' experience)

This section is very important, please fill out in detail.

Are there any other experiences, skills, or qualifications
that you feel would especially qualify you for employment at
our company?

If applying for a position requiring the use of a vehicle,
please complete the following:

Are you licensed to drive?
No Yes
If yes, in what state?

Driver license number:

What type(s) of licenses do you have?

Operators Chauffeur Other

Do you own (or have primary access to) a car?
No Yes

PLEASE READ THE FOLLOWING BEFORE SUBMITTING
THIS APPLICATION:

I understand that:

1. A-A American Agency may conduct an investigation of my
   credit record and I consent to such an investigation.
   Under the Fair Credit Reporting Act, A-A American Agency
   is required to inform me of my right to have the nature
   and scope of any investigation, if conducted by an
   outside agency, described to me by that agency if I so
   desire.

2. I may be required to take a physical examination, at A-A
   American Agency expense, to assist in determining my
   employment eligibility.

3. If employed, my continued employment is subject to
   satisfactory reference checks. For this purpose, I
   hereby authorize investigation of all statements
   contained in this application, and understand that       
   misrepresentation or omission of facts called for is
   cause for dismissal.
 
4. If employed, my tenure is NOT guaranteed and is subject
   to termination at will or without cause.

5. The first six (6) months of employment with A-A American
   Agency is on a probationary basis.

6. I agree and consent that any wages, which may be due to
   me, may be applied against any indebtedness I may have
   incurred to A-A American Agency (applicable to
   federal/state law).

I affirm that everything is true and correct, and I
acknowledge that I can be terminated at any time if it turns
out that any information I supply is false. I affirm that I
have a genuine intent and no other purposes in applying for
a job with A-A American Agency.

YOUR FULL NAME

DATE