Fields marked * are mandatory

    Personal Info

    First Name*

    Middle Name

    Last Name*

    Maiden Name / Aliases / Other Names / Etc

    Position Applied For*

    Current Address Information

    Street Address*

    City*

    State*

    Zip*

    County*

    Date of Birth*

    Social Security No*

    Driver’s License No

    State Issued

    Insurance Agent License No.

    State Issued

    Exp. Date

    Home Telephone

    Cell Telephone*

    Email*

    Salary Expected

    Hours Available to work

    Emergency Info

    Name of person to contact in case of an accident or emergency

    Relationship

    Home Telephone

    Cell Telephone

    Work Telephone

    Address of person to notify in case of an accident or emergency

    Personal Questions

    If you are hired, when are you available to start work?*

    List states in which you are currently hold a professional license:*

    List dates in which professional licensure was received:

    Has your professional license ever been suspended or revoked? If yes, please specify.

    Please indicate the number of moving violations (including all driving violations, DUI and OUI) and the year they occurred.

    Have you ever been convicted of a crime? If yes, please specify.

    Are there any felony charges pending against you? If yes, please specify.

    Are you a citizen of the USA?

    If you are not a citizen of the USA, are you legally authorized to work in this country?

    Recent Employment History (List most recent position first)

    Employment History #1

    Company

    (Beginning) month/year

    (Ending) month/year

    Address

    City

    State

    Zip Code

    Name and title of your immediate supervisor

    Telephone Number

    May we contact?

    Your duties and responsibilities

    (Beginning) Rate of Pay

    (Ending) Rate of Pay

    Reason for leaving

    Employment History #2

    Company

    (Beginning) month/year

    (Ending) month/year

    Address

    City

    State

    Zip Code

    Name and title of your immediate supervisor

    Telephone Number

    May we contact?

    Your duties and responsibilities

    (Beginning) Rate of Pay

    (Ending) Rate of Pay

    Reason for leaving

    Please detail any lapses between employment

    Education

    High School (Name and Location)

    Attended

    To

    Graduation Date

    College (Name and Location)

    Attended

    To

    Major

    Minor

    Degree

    Graduation Date

    Other School (Name and Location)

    Attended

    To

    Date Completed and skills obtained

    Special training or achievements (Specify if current)

    Professional references

    (Persons who have SUPERVISED your professional work; excluding friends or relatives)
    This information is required to be considered for a position with our company.

    Reference #1

    Name

    Address

    City/State

    State

    Zip Code

    Company Name

    Telephone Number

    Relationship to Job Applicant

    Reference #2

    Name

    Address

    City/State

    State

    Zip Code

    Company Name

    Telephone Number

    Relationship to Job Applicant

    WRITTEN CONSENT / READ THIS SECTION CAREFULLY

    I authorize National Health Plans & Benefits Agency, LLC (the “Company”), to obtain information about me from my previous employers, schools, and credit sources and to conduct a criminal background and driving check. I hereby authorize National Health Plans & Benefits Agency, LLC to contact, obtain, and verify the accuracy of information contained herein this application from all previous employers, educational institutions, and references. I also hereby release from liability National Health Plans & Benefits Agency, LLC and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. Additionally, I hereby agree, upon a request made under the drug/alcohol testing policy of National Health Plans & Benefits Agency, LLC to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination or non-consideration for employment. I agree that if selected for employment by the Company, this authorization shall serve as advanced written consent for future drug and alcohol testing. I further authorize and give full permission to have the Company and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the Company’s policies, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I authorize all parties stated herein to release such information as your needs require, including my prior disciplinary employment record and credit reports, without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquires and disclosures. I also understand that I am able to request a copy of any records obtained and that any requests for this information must be done in writing and submitted to the prospective employer within 30 days of the initial application. Further, I have read and understand this Application and the Disclosure Regarding Consumer and/or Investigative Report, and I have been made aware that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics and mode of living. I also agree that a fax or photocopy of this authorization with my signature be accepted with the same authority as the original. National Health Plans & Benefits Agency, LLC is an equal employment opportunity employer. National Health Plans & Benefits Agency, LLC adheres to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age, height, weight, or disability. National Health Plans & Benefits Agency, LLC assures you that your opportunity for employment depends solely upon on your qualifications and the information provided and disclosed herein.

    DISCLOSURE (Regarding Consumer and/or Investigative Report)

    A consumer report and/or investigative consumer report including information concerning your character, employment history, general reputation, personal characteristics, police record, criminal records, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness may be obtained in connection with your application for and/or continued employment with the employer. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the company. These reports may include experience information along with reasons for termination of past employment. Further, understand that information from various Federal, State, local and other agencies which contain your past activities may be requested. A consumer report containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made.

    I Agree to the above mentioned Terms and Conditions*

    e-signed By*

    Attach your Resume*