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Employment Application
Call Us Today
(423) 994-4200
Employment Application
Position Applying for:
Application Date:
MM slash DD slash YYYY
Name
First
MI
Last
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
Alternate #
Email
Alternate Email
Are you available to work:
Full time?
Part time?
If you are under 18 years of age, can you provide required proof of work eligibility?
Yes
No
N/A
Do you or will you in the future require sponsorship for employment visa status?
Yes
No
Have you ever worked or submitted an application with this agency before?
Yes
No
If yes, when:
Are you currently employed?
Yes
No
Are you currently on layoff status and subject to recall?
Yes
No
May we contact your current employer?
Yes
No
Are you eligible to work in the United States? (Proof of eligibility will be required upon employment.)
Yes
No
Do you have a reliable means of transportation?
Yes
No
Have you ever been discharged from any employment or been asked to resign? (If yes, attach explanation.)
Yes
No
Are you bound by any agreement(s), including signing a non-competition, non-disclosure, non-solicitation, or non-piracy agreement? (If yes, attach copy to this application.)
Yes
No
Are you able to perform all the essential functions of the job for which you are applying with or without reasonable accommodation?
Yes
No
If hired, would you be able to travel out of town/overnight?
Yes
No
If hired, would you be able to work overtime or weekends as needed?
Yes
No
Employment
Do you want to include previous employment history?
Yes
No
Employer
Number
Full Address (Street, City, State & Zip)
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Reason for Leaving
Describe work performed
Do you want to include a second employer's information?
Yes
No
Employer
Number
Full Address (Street, City, State & Zip)
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Reason for Leaving
Describe work performed
Do you want to include a third employer's information?
Yes
No
Employer
Number
Full Address (Street, City, State & Zip)
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Reason for Leaving
Describe work performed
Do you want to include a fourth employers' information?
Yes
No
Employer
Number
Full Address (Street, City, State & Zip)
Supervisor’s Name & Title
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Reason for Leaving
Describe work performed
Education
Name of School
Address of School
Grade Completed / Degree(s)
Subjects Studied
List any seminars, classes, or other education not listed above which may help qualify you for this position.
Optional: List any professional, trade, business, or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability, gender orientation, or any other protected status.
Optional: List any languages other than English that you can speak, read, or write that may be of benefit to the position applied for.
Designations
Check all that apply
CIC
CPCU
CLU
ChFC
CRM
CISR
Other Designations:
Licenses
List State & License # if you have the following:
P&C License
L&H License
Broker’s License
Series 6 or 7 License
List Any Other Licenses with State & License #
If you have ever had an insurance license suspended or revoked, include details and explanation.
References
Include 3 professional references
Name
Address
Phone #
Title/Company
Relationship
Email
Additional Experience of Qualifications
List any other experience, skills, or qualifications that you believe should be considered in evaluating your qualifications for employment.
If hired, what value would you bring to our company?
Describe what you believe are the most unique features of your work history.
If hired, what value would you bring to our company?
Notification and Agreement
It is Rock Creek Insurance Inc.’s policy to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or sexual orientation, individuals with a disability, or any other characteristic protected by applicable Federal, State, or Local law.
I authorize the investigation of all statements and information contained in this application. I release from liability anyone supplying such information, and I also release Rock Creek Insurance Inc. from all liability that might result from making an investigation.
If employed, I agree to not engage in any outside activity that would involve a material conflict of interest with, or could reflect adversely on Rock Creek Insurance Inc. I understand that Rock Creek Insurance Inc. retains the right to solely decide when such a conflict exists.
If employed, I agree to hold in strictest confidence any information concerning Rock Creek Insurance Inc, its Insureds, and its Carriers that may come to my knowledge.
In consideration of my employment, if I am employed, I agree to conform to the employment policies of Rock Creek Insurance Inc. and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Rock Creek Insurance Inc. or myself. I understand that no representative of Rock Creek Insurance Inc. other than the President, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.
I understand that completion of this employment application does not guarantee that I have been employed by Rock Creek Insurance Inc. By signing this application, I indicate that I understand that this company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline up to and including termination.
I understand that if I am offered a position with this company, I may be given a pre-employment drug/alcohol test as a condition of employment. My refusal to submit to a drug/alcohol test in a timely manner, or my failure to pass such a test means that I will not be employed by this company without lawful and approved documentation of any such substance found in such a test. Negative test results are required as a condition of employment. Test results will be kept confidential.
I understand and agree that if I am employed, my employment will be at will, which means that the company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the company will respect my right to terminate my employment at any time with or without cause and with or without notice.
I authorize investigation into all statements and references contained in this application. Said investigation may include interviews with past employers, workers, and friends.
I understand that the company is under no obligation to hire me as the result of accepting this completed application.
I certify that all answers given by me are true, accurate, and complete pursuant to the penalty of perjury under the laws of this state. I certify that I have not knowingly withheld any information that might adversely affect my chances for employment. I understand that the falsification, misrepresentation, or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
Comments
This field is for validation purposes and should be left unchanged.
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