DATES (MO, & YEAR)	NAME AND LOCATION (CITY, STATE) OF FIRM	JOB TITLE/ SALARY	WORK PERFORMED	REASON FOR LEAVING
1. PRESENT OR MOST RECENT     EMPLOYMENT		Starting Title Final Title Starting Salary Final Salary
Start Thru
	Phone		Your supervisor
2. EMPLOYMENT IMMEDIATELY     PRIOR TO NO. 1		Starting Title Final Title Starting Salary Final Salary
Start Thru
	Phone		Your supervisor
3. EMPLOYMENT IMMEDIATELY     PRIOR TO NO. 2		Starting Title Final Title Starting Salary Final Salary
Start Thru
	Phone		Your supervisor
4. EMPLOYMENT IMMEDIATELY     PRIOR TO NO. 3		Starting Title Final Title Starting Salary Final Salary
Start Thru
	Phone		Your supervisor

 
Explain any gaps in employment dates


If discharged from any employer listed above, list name of employer and accurately describe the circumstances.


Have you been convicted of a felony?   Yes   No
If Yes, describe the type of crime, the date of conviction and please explain the circumstances. You are not obligated to disclose sealed or expunged records of conviction or arrest. A conviction will not necessarily disqualify you from employment.


Are you currently employed?   Yes   No

May we contact your current employer?   Yes   No

	NAME OF SCHOOL	LOCATION	MAJOR SUBJECT	# OF ACADEMIC YEARS COMPLETED
High School				Graduate? y n   yrs.
College				Degree? y n   yrs.
College				Degree? y n   yrs.
Vocational or Trade				Certificate or Degree? y n   yrs.

What is your personal computer experience?
	Well trained and experienced. Length of experience (years & months) .
	Some training or exposure, but no actual work experience.
	No training or exposure

 
List any special skills (i.e., approximate words per minute typing skills), software packages you have experience with, training, licenses, certificates or special work-related qualifications you have that are not indicated elsewhere on this application

Are you a member of the immediate family (brother, sister, son, daughter, father, mother or in-laws of any of these) of anyone now employed by Bituminous Insurance Companies? *Yes   No   If yes, please indicate employee's name and your relationship to them.

 

APPLICANT’S CERTIFICATION I AUTHORIZE THE INVESTIGATION OF ALL STATEMENTS CONTAINED ON THIS APPLICATION AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND EDUCATION, AND RELEASE ALL PERSONS FROM ALL LIABILITY AND DAMAGES THAT MAY RESULT FROM FURNISHING THAT INFORMATION TO YOU. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF BITUMINOUS, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF EITHER BITUMINOUS OR MYSELF. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY BITUMINOUS. I UNDERSTAND THAT NO REPRESENTATIVE OF BITUMINOUS, OTHER THAN ITS PRESIDENT, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING. I CERTIFY THAT I HAVE READ AND UNDERSTAND THE FOREGOING PARAGRAPHS. I FURTHER CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT ANY FALSE INFORMATION, MISREPRESENTATION, OR OMISSIONS OF FACTS MAY RESULT IN THE DENIAL OF MY APPLICATION, OR, IF I AM EMPLOYED, DISCHARGE AT ANY TIME.

 
* indicates a required field.