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Home > Employment Application
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Employment Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Blackwood Insurance Group, PA Employment Application
Date of Application: *
/ /
Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Social Security Number *
My work availability is: *
Have you ever worked or submitted an application with this agency before? *
Are you currently employed? *
May we contact your current employer? *
Are you eligible to work in the United States? (Proof of eligibility will be required upon employment.) *
Have you ever been convicted of a crime, excluding minor traffic violations? *
If above is yes, please explain (required if above is yes):
Do you have a reliable means of transportation? *
Have you ever been discharged from any employment or been asked to resign? (If yes, explain below:) *
If above is yes, please explain (required if above is yes):
Are you bound by any agreement(s) (including signing a non-competition, non-disclosure, or non-piracy agreement) that would limit your ability to work for the agency? *
If above is yes, upload a copy of the agreement(s) here:
Employment
Start with MOST RECENT employment and then work backwards. There will be an opportunity to explain gaps in employment, as well.
Current / Most Recent Employment
Information about my Current or Most Recent Employment:
Employer *
Telephone Number: *
Full Address (Street, City, State & Zip): *
Supervisor's Name and Title: *
Employment START Date *
/ /
Employment END Date *
/ /
Ending Compensation *
Reason for Leaving *
Describe the work you performed: *
Next Most Recent Employment
Employer *
Telephone Number: *
Full Address (Street, City, State & Zip): *
Supervisor's Name and Title: *
Employment START Date *
/ /
Employment END Date *
/ /
Ending Compensation *
Reason for Leaving *
Describe the work you performed: *
Next Most Recent Employment
Employer *
Telephone Number: *
Full Address (Street, City, State & Zip): *
Supervisor's Name and Title: *
Employment START Date *
/ /
Employment END Date *
/ /
Ending Compensation *
Reason for Leaving *
Describe the work you performed: *
Education
High School
Name of High School *
City & State of High School *
Highest Grade Completed *
Start with your MOST RECENT college first, then work backwards from there.
Most Recent College
College / Technical School Name
College / Technical School City & State
College / Technical School Degree(s) or Certification(s) earned:
Next Most Recent College
College / Technical School Name
College / Technical School City & State
College / Technical School Degree(s) or Certification(s) earned:
Next Most Recent College
College / Technical School Name
College / Technical School City & State
College / Technical School Degree(s) or Certification(s) earned:
Insurance Licenses
Do you have a P&C License? *
If "yes" State & License # (if none, write "none") *
Do you have a L&H License? *
If "yes" State & License # (if none, write "none") *
Other Licenses:
References
Please include at least two business and one personal reference.
Reference 1
Name *
Telephone Number: *
E-mail Address: *
Full Address (Street, City, State & Zip): *
Company Name *
Relationship *
Reference 2
Name *
Telephone Number: *
E-mail Address: *
Full Address (Street, City, State & Zip): *
Company Name *
Relationship *
Reference 3
Name *
Telephone Number: *
E-mail Address: *
Full Address (Street, City, State & Zip): *
Company Name *
Relationship *
Additional Information
LANGUAGES - List ALL languages you speak and understand fluently:
How many words per minute do you type correctly? *
AGENCY MANAGEMENT SYSTEMS - List any AMS systems, if any, that you've used in your previous employment.
List any other experience, skills or qualifications that you believe should be considered in evaluating your qualifications for employment.
Do you have a resume'? *
If you have a resume', please upload it here:
If you'd like to upload your references, please do so here:
It is Blackwood Insurance Group, PA's policy to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national original, marital status or sexual orientation, individuals with a disability, or any other characteristic protected by applicable Federal, State or Local law. I authorize the investigation of all statement and information contained in this application. I release from liability anyone supplying such information and I also release Blackwood Insurance Group, PA from all liability that might result from making an investigation. If employed, I agree to not engage in any outside activity that would involve a material conflict of interest with, or could reflect adversely on Blackwood Insurance Group, PA. I understand that Blackwood Insurance Group, PA retains the right to solely decide when such conflict occurs. If employed, I agree to hold in strictest confidence any information concerning Blackwood Insurance Group, PA, its Insureds, its Prospects and its Carriers that may come to my knowledge. In consideration of my employment, if I am employed, I agree to the employment policies of Blackwood Insurance Group, PA, and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Blackwood Insurance Group, PA or myself. I understand that the completion of this employment application does not constitute an offer of employment, nor guarantee that I will be employed by Blackwood Insurance Group, PA. I certify that all answers given by me are true, accurate and complete, I understand that the falsification, misrepresentations or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
Affirmation *
Type your Full Name: *
Date *
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Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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