CORPORATE RECRUITING
1301 Dove Street, Ste. 200
Newport Beach, CA. 92660
(949) 260-5005
fax (949) 809-1475
Fax Cover Sheet
Dear Applicant,
Prior to your interview, use this fax cover sheet along with the attachments to
complete the following required actions as part of the application process:
1. Type your information into every section using Microsoft Word (preferred)
or clearly write in information (print)
2. If typed, print out the completed Word document
3. Sign & date the document in blue or black ink (in 2 different places)
4. Fax the application (to 949-809-1475) using this fax cover sheet
Incomplete information or missing signatures will delay the process and/or
disqualify you from further consideration.
You may present the original application to the interviewing manager.
Thank you.
ATTN:
Alliant Corporate Recruiting
TO: Pam Tabert, Corporate Recruiter
Email: ptabert@alliantinsurance.com
Fax: (949) 809-1475
Phone: (949) 260-5005
From:
Telephone #:
Email address:
RE:
Employment Application
JOB I.D. # (From internet posting):
Position Applied for:
Location:
Interviewing Manager (if applicable)
TOTAL PAGES:
(including fax coversheet)
CHECKLIST OF INFORMATION TO INCLUDE:
Employment Application – Completed in full
Sign Employment Application – 2 different places
Include Referenced Job I.D. #
APPLICATION FOR EMPLOYMENT
Incomplete information could disqualify you from further consideration.
Application must be completed in full even if attaching a resume.
PERSONAL INFORMATION
Date of Application:
Name:
Last
First
Middle
Address:
Street Address
(
)
City
-
(
Home Phone
)
State
Zip Code
-
Cell Phone
Email Address
How did you learn about this position?
Have you previously applied or worked at Alliant or any
subdivision? If so, when and what location:
Name of Position Applying for:
GENERAL INFORMATION
What date are you
available to start work?
Type of schedule:
Desired
Wage/Salary $
Full-time
Part-time
.
If part-time, how many hours per week?
Are any of your relatives presently employed with the company or its divisions?
If yes, name of relative(s)
Are you authorized to work
in the United States
Yes
No
per
Yes
No
If offered a position, the Immigration Reform & Control Act of 1986 (with
amendments) requires you to furnish proof of your employment authorization
and your identity before you begin work.
Have you ever been convicted of a criminal offense (any felony or any misdemeanor)?
Yes
No
If you answered yes, state the nature of the crime(s), when and where convicted and disposition of the case.
Convictions for marijuana-related offenses that are more than two years old need not be listed.
Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date
of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.
Description in full:
Have you ever been discharged from any employment or asked to resign?
Yes
No
If yes, describe circumstances:
EDUCATION INFORMATION
Education
School Name, Campus, Address
Indicate Last
Year Completed
Graduated
HIGH SCHOOL
City, State
9 10 11 12
Yes
No
COLLEGE (S)
City, State
1
2
Yes
No
GRADUATE
SCHOOL
City, State
1
2
1
2
3
4
Do you possess a valid Professional Insurance
License #
License?
Yes
No
In which state(s) do you possess a valid professional insurance license?
Type:
Broker
Agent
P&C
Surplus Lines Broker
Life/Health
Any Professional Designations?
CPCU
CLU
CIC
AAI
ARM
or
Diploma
Other
GED
Yes
No
OTHER
City, State
Degree / Major
3
4
Yes
No
State of residence license:
Other (please describe):
CISR
Other:
-Equal Employment OpportunityIt is the policy and practice of Alliant Insurance Services, Inc., to recruit and select applicants on the basis of their qualifications and ability without regard race,
religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition (record or history of cancer), marital status, sex (including
pregnancy, childbirth, and gender identity), age (40 years and older), or sexual orientation of any person, unless a bona fide occupational qualification (BFOQ)
applies (CA Gov. Code Sec. 12940, Sec. 12926(p)). “Sexual orientation” is defined as meaning heterosexuality, homosexuality, and bisexuality (CA Gov. Code
Sec. 12926(q)). Affirmation measures shall be applied by every means possible to make known to employees and potential applicants that equal employment
opportunities are available at Alliant Insurance Services, Inc.
Page 2
Rev. 05.25.11
Present/Most Recent Employer:
Last or Present Position/Responsibilities:
Company:
Start Date:
Supervisor/Title:
Termination Date:
Please indicate when we may contact human resources to verify present
employment:
Now
Starting Position/Responsibilities:
Later, if offer is extended and accepted
EMPLOYMENT HISTORY
Company Address:
Phone Number:
End base salary:
$
Per
Additional comp
Reason for Leaving:
$
Per
Last Position/Responsibilities:
Previous Employer:
Company:
Start Date:
Termination Date:
Supervisor/Title:
Company Address:
Starting Position/Responsibilities
Phone Number:
End base salary:
$
Per
Additional comp
Reason for Leaving:
$
Per
Last Position/Responsibilities:
Previous Employer:
Company:
Start Date:
Termination Date:
Supervisor/Title:
Company Address:
Starting Position/Responsibilities:
End base salary:
$
Per
Additional comp
Reason for Leaving:
$
Per
MILITARY
Phone Number:
List any Patents of Publications (Attach separate sheet if necessary.):
Have you ever served in the U.S. Armed Forces?
Yes
No
Branch of Services:
Provide at least three (3) names of former supervisors / individuals who are familiar with your work capabilities.
List two professors if you are a student.
*Check the boxes of professional references you are authorizing us to contact upon the date of signing this document.
REFERENCES
Professional Reference (Name)
Position Title / Company
Telephone
(
)
-
(
)
-
(
)
-
*Yes, I authorize you to contact now
*Yes, I authorize you to contact now
*Yes, I authorize you to contact now
If hired, this application will become part of your official employment record.
List any other LAST NAME
/NICKNAME used:
Applicant Signature:
Page 3
Date:
Rev. 05.25.11
APPLICANT’S CERTIFICATION AND ACKNOWLEDGEMENT
1. I understand that any offer of employment regarding certain job positions may be conditioned
on satisfactory completion of a medical examination and/or drug and alcohol testing should the
Company condition my offer of employment upon successful completion of such an
examination or testing.
2. I hereby certify, under penalty of perjury, that all of the information in the application of
employment is true and complete, and I understand that any misrepresentation, falsification or
omission of information may result in the denial of employment or, if hired, may result in
immediate dismissal regardless of the time elapsed before discovery.
3. I authorize the Company to contact my former employers, references, and all other persons and
organizations for information bearing upon my qualifications and suitability for employment. I
further authorize my former employers, references, schools and any other organization to
disclose to the Company (without giving my prior notice of such disclosure) any and all
information about my previous employment and education, along with other pertinent
information they may have.
4. I expressly agree and understand that, if employed; my employment is for an unspecified term
and is at-will. Therefore, my employment can be terminated, with or without cause, and with or
without prior notice, at any time, at my option or at the company’s option. Although other terms
or conditions of employment may change, this at-will employment relationship will remain in
effect throughout my employment. I also understand that this aspect of my employment, which
includes the Company’s right to demote or otherwise discipline with or without cause or notice,
may not be changed, modified, amended or rescinded except by an individual written
agreement signed by both me and either the Chief Executive Officer, Chief Financial Officer or
the Chief Operations Officer.
5. Except as required in the performance of my duties, I understand and agree that if I am hired I
will not at any time during or after my employment use, disclose or disseminate any confidential
information or any other information of a secret, proprietary, or generally undisclosed nature
relating to the Company or its products, services, customers, employees, plans or procedures.
I agree to deliver to the Company any and all copies of confidential information, or other
Company property, upon termination of the employment relationship or at any time upon the
Company’s request. I also agree not to solicit customers or employees of the Company either
during my employment or after my employment termination.
6. The statements above supersede and replace any prior understanding or discussions I have
had with the Company and set forth the complete agreement between the Company and me
regarding these matters.
I certify that I have read, fully understand and accept all of the above terms and
statements.
Print Name:
Signature of Applicant : ___________________________________Date:___________________
Page 4
Rev. 05.25.11