The undersigned, in connection with this application, authorizes all corporations, companies,
credit agencies, educational institutions, persons, law enforcement agencies, military services
and former employers to release information they may have about me to The John Galt
Insurance Agency or its agents and releases themfrom any liability or responsibility from doing
so. Further, I authorize the procurement of aninvestigative consumer report and understand
that such a report may contain information about my background, character, criminal record
search and personal reputation. I understand that this notice will also apply to any future update
reports that may be requested.
I understand that The John Galt Insurance Agency Corporation retains the sole right to determine
terms and conditions of employment.
I also understand that Federal Law prohibits The John Galt Insurance Agency Corporation from
hiring persons who are not authorized to work inthe United States. I represent that I possess
unrestricted employment authorization and will provide The John Galt Insurance Agency
Corporation with documents verifying my identity and employment eligibility if and when I am
In addition, I understand that misrepresentation or false information on this application can result
in discontinuation of employment consideration or, if I am employed, my discharge.
I authorized The John Galt Insurance Agency Corporation to contact:
Any previous employer,
Any education institution I have attended; and,
Personal referenced I have listed
To make any investigation of my personal, financial, and credit background necessary for the
purpose of evaluating my qualifications for employment. This authorization and application
extends for twelve (12) months from today’s date.