Application for Employment

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on
any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status,
political belief, or disability that does not prohibit performance of essential job functions.

Personal Information

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit
satisfactory proof of employment authorization and identity (valid driver's license, birth
certificate, Green Card, etc.) within three days of being hired. Failure to submit such proof
within the required time shall result in immediate employment termination.
6) Is your personal credit rating? *
7) Are you legally authorized to work in the United States? *

Education History

High School Name / Location / Year Completed / Degree/Diploma *
College Name / Location / Year Completed / Degree/Diploma
Other / Location / Year Completed / Degree/Diploma

Employment History

Employer 1
May we contact? *
Employer 2
May we contact?
Employer 3
May we contact?
Employer 4
May we contact?


Reference 1
Reference 2
Reference 3


Work Availability

1) Do you have any objection to working overtime? *
2) Can you work overtime without prior notice? *
3) Can you work on Saturday? *
4) Can you travel if required by this position? *

Salary or Hourly Rate Requirements

Authorization and General Release

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
offered employment.
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.
FLORIDA is an At-Will Employment State, I acknowledge that if hired I will be an at
will employee, and as such, both the employer and I reserve the right to terminate
employment at any time, with or without notice, and with or without cause.
Signature *
Print Name *

Internal Use Only