Application – Mona's Insurance

Position Applied For:*

Today's Date*

Name*

First Last

Home Phone*

Work Phone

Current Address*

Street Address Address Line 2 City State ZIP Code

Prior Address

Street Address Address Line 2 City State ZIP Code

What date can you start?

What category would you prefer?

Full time
Part time
Temporary
Labor Pool

For which schedules are you available?

Weekdays
Weekends
Evenings
Nights
Overtime
Shift
Other

Other*

Job-Related Skills

Have you ever been given a job description or had the essential functions of the job explained to you?

Yes
No

Do you understand these essential functions?

Yes
No

After carefully reviewing the job description and physical requirements of the job for which you are applying, are you able to perform the essential function sof the job with or without reasonable accommodation?

Yes
No

Professional Licenses and Certifications

Are you licensed/certified for the job applied for?

Yes
No

Name of license/certifications*

License/certification number*

Has your license/certification ever been revoked or suspended?

Yes
No

If yes, state the reason(s), date of revocation or suspension, and date of reinstatement:*

References

Include only individuals familiar with your work ability. Do not include relatives or names of supervisors listed.

Name

First Last

Address / Phone

Years Known/Relationship

Name

First Last

Address / Phone

Years Known/Relationship

Name

First Last

Address / Phone

Years Known/Relationship

Education

Highest Level of Education Completed

High School Name

City/State

Graduated?

Yes
No

College Name

City/State

Graduated?

Yes
No

Other

City/State

Graduated?

Yes
No

Previous Employers

PLEASE NOTE: Your application may not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. FOR EMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY. In Massachusetts an applicant may include any verified work performed on a volunteer basis.

Most Recent Employer

Are you currently working for this employer?

Yes
No

If yes, may we contact?

Yes
No

Company Name

Supervisor Name

Duties

Phone

Reason for Leaving

Salary

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Most Recent Employer

Company Name

Supervisor Name

Duties

Phone

Reason for Leaving

Salary

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Third Most Recent Employer

Company Name

Supervisor Name

Duties

Phone

Reason for Leaving

Salary

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fourth Most Recent Employer

Company Name

Supervisor Name

Duties

Phone

Reason for Leaving

Salary

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Background Information

If the job requires, do you have the appropriate valid driver's license?

Yes
No

Name on License:*

DL#*

Type*

State of Issue*

Have you had any moving violations in the past seven years?

Yes
No

Please describe:

Criminal History

Please note that a "Yes" answer to any of the following questions will not necessarily disqualify you from employment. Factors such as the age and time of the offense, seriousness and nature of the violation, and rehabilitation will be considered when making any employment decisions.

NOTE: Before answering this question regarding criminal convictions, please refer to the instructions below if you reside or are applying for a position in California, Connecticut, District of Columbia, Georgia, Hawaii, Massachusetts or Washington.

Please explain any "Yes" answer.

Have you ever been convincted of a crime? Do not include convictions that were sealed or expunged pursuant to a court order.

Yes
No

Please explain:

Are you currently awaiting trial for any criminal offense?

Yes
No

Please explain:

Have you ever initiated an act of violence in the workplace?

Yes
No

Please explain:

Instructions for Answering Criminal Conviction Inquiry

California Applicants: Do not identify any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been dismissed by a court. Also, do not identify marijuana-related convictions entered by the court more than 2 years ago that involve: unlawful possession of marijuana; transportation or giving away up to 28.5 grams of marijuana, other than concentrated cannabis, or the offering to transport or give away up to 28.5 grams of marijuana, other than concentrated cannabis; possession of paraphernalia used to smoke marijuana; being in a place with knowledge that marijuana was being used; or being under the influence of marijuana.

Connecticut Applicants: Applicants are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased pursuant to section 46b – 146, 54 -76o or 54 – 142a of the Connecticut General Statutes. Criminal records subject to erasure under these sections are records pertaining to a finding of delinquency or the fact that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received an absolute pardon. Any person whose criminal records have been erased pursuant to these sections is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and so may swear under oath.

District of Columbia Applicants: Do not identify any guilty plea that was discharged by the court under Georgia’s First Offender Act.

Hawaii Applicants: Do not answer this question at this time. You will only have to answer this question if you receive a conditional offer of employment. At that time, you will be asked whether you have been convicted of a crime within the past ten (10) years.

Massachusetts Applicants: An applicant for employment with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, an applicant for employment may answer “no record” with respect to an inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. Massachusetts applicants should not disclose information regarding first-time misdemeanor convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace. Finally, Massachusetts applicants should not disclose convictions for other misdemeanors where the date of conviction or the end of any period of incarceration was more than five years ago unless there have been subsequent convictions within those five years.

New York Applicants: You may answer “no record” concerning any criminal proceeding that terminated in your favor, per section 160.50 of the New York Criminal Procedure Law; any criminal proceeding that terminated in a “youthful offender adjudication”, as defined in section 720.35 of the New York Criminal Procedure Law; a conviction for a “violation” that has already been sealed by the court, per section 160.55 of the New York Criminal Procedure Law.

Washington Applicants: Do not identify any conviction that is more than ten (10) years old at the time of making this application. INSTRUCTIONS FOR ANSWERING CRIMINAL CONVICTION INQUIRY ©

Applicant Note

This application form is intended for use in evaluating your qualifications for employment. This application form is not an offer of employment. If hired, such employment shall be considered “at will” and this application is not intended to constitute a contract of continued employment. False or misleading statements during the interview or on this form may result in the refusal to hire or termination of employment. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability, or any other consideration made unlawful by applicable federal, state or local laws. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you may be required to complete a medical history form and may be required to be examined by a medical professional designated by the company. Smoking is prohibited in all indoor areas of the Company's facilities unless designated smoking areas have been established at a particular location in accordance with applicable state and local law.

"Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $ 100."

Maryland applicants, please sign and acknowledge receipt of the above notice.

Signature:

Date

Massachusetts Applicants: "It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability."

Rhode Island Applicants:The Company is subject to Chapters 29-38 of Title 28 of the General Laws of Rhode Island, and is therefore covered by the state's workers' compensation law.

Permission to Work in the United States

Are you legally eligible to work in the United States?

Yes
No

Proof of employment eligibility will be required if hired.

Certification and Release

I certify that I have read and understand the applicant note on this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Signature

Date