Gaylor Insurance may be the career for you!


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:
State:
Zip:
Home Telephone:
Daytime Phone:
Email Address:
  

Position Information

What position are you interested in? 
Comments:


 
Desired Salary:
  
Willing to relocate? Yes      No
  
Full Time or Part Time? Full Time     Part Time
  
If Part Time, how many hours a 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 Visa
or immigration status?		 Yes    No

  

Education Information

High School Name:
City:
State:
Receive High School Diploma? Yes       No
College/University:
City:
State:
Zip:
How many years of college have you
completed?

What is/was your course of study?



Please list other Schooling:
  

Job Related Skills

List any languages other then English
that you speak fluently:


List all knowledge of computer programs:



Mark all skills that apply:



 Word Processing
 10 Key Adding Machine
 Typing WPM
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 felony? If yes, please
explain:

Background Authorization

If I am interviewed and accept
employment, I agree to allow the
company to investigate my back
ground.		 Yes    
  

Employment Experience

Please go back 5 years, listing your most recent employer first. Include any gaps in employment and state the reason for no employment during that period.
Employer:
Address:
City:
State:
Zip:
Phone:
Job Title:
Supervisor:
Start Date:
End Date:
Starting Salary/Hourly Wage:
Ending Salary/Hourly Wage:
Reason For Leaving:
  

Employer:
Address:
City:
State:
Zip:
Phone:
Job Title:
Supervisor:
Start Date:
End Date:
Starting Salary/Hourly Wage:
Ending Salary/Hourly Wage:
Reason For Leaving:
  

Employer:
Address:
City:
State:
Zip:
Phone:
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:
Relationship:
Number of Years Known:
  
    
Name:
Address:
Phone:
Relationship:
Number of years known:
  
    
Name:
Address:
Phone:
Relationship:
Number of years known:
  
    
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.