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Robert Totsky Insurance

6050 N. Oracle Rd, Suite A

Tucson, Arizona  85704

Phone:  520-750-1166

Fax:  520-844-8018

Email:  rtinsurance@msn.com

 

EMPLOYMENT APPLICATION

Pre-Employment Questionnaire An Equal Opportunity Employer

 

PERSONAL INFORMATION

Full Name:
Social Security No.:
Present Address:
Street / Apt. # / City / State / Zip Code
Permanent Address:
Street / Apt. # / City / State / Zip Code
Phone:
Are you 18 years or older?  Yes  No

DESIRED EMPLOYMENT
Position:
Date you can start:
Salary Desired:
Are you employed now?  Yes  No
If so, may we inquire of your present employer?  Yes  No
Ever applied to this company before?  Yes  No
Where?    When?
Ever worked for this company before?  Yes  No
Where?    When?

Reason for leaving:
Name of last supervisor at the company: 
Who referred you to this company?
Employment Agency  Newspaper Ad  Friend
State Employment Office  College Placement Service
Walk-In   Other
EDUCATION
Grammar School:
Address:
No. of years attended:   Graduate? Yes No
Subjects Studied:
   
High School:
Address:
No. of years attended:   Graduate? Yes No
Subjects Studied:
   
College:
Address:
No. of years attended:   Graduate? Yes No
Subjects Studied:
   
Trade / Business
or Correspondence
School:
Address:
No. of years attended:   Graduate? Yes No
Subjects Studied:
GENERAL
Subjects of special study or research work:
Special training:
Special skills:
FORMER EMPLOYERS
List below last three employers, starting with the most recent.
Name of Present or last employer:
Address / City / State / Zip Code:
Starting Date:    Leaving Date:
Job Title: 
Starting Salary:   Ending Salary:
Supervisor:   Title:
May we contact your supervisor?  Yes No
Phone: 
Description of work:
Reason for leaving:
 
Name of Previous employer:
Address / City / State / Zip Code:
Starting Date:    Leaving Date:
Job Title: 
Starting Salary:   Ending Salary:
Supervisor:   Title:
May we contact your supervisor?  Yes No
Phone: 
Description of work:
Reason for leaving:
 
Name of Previous employer:
Address / City / State / Zip Code:
Starting Date:    Leaving Date:
Job Title: 
Starting Salary:   Ending Salary:
Supervisor:   Title:
May we contact your supervisor?  Yes No
Phone: 
Description of work:
Reason for leaving:
REFERENCES
Below, give the names of three persons you are not related to, whom you have known at least one year.
Name Occupation Phone Years
Known

SERVICE RECORD
Branch of Service Discharge Date / Rank
 
Have you been convicted of a felony within the last 5 years?
Yes No
If yes, explain (will not necessarily exclude you from consideration)

AUTHORIZATION

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."

Name:     Date: 

Please e-Mail a copy of your resume in Microsoft Word or PDF format to:  rtinsurance@msn.com .

    

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