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APPLICATION FOR EMPLOYMENT
BITUMINOUS INSURANCE COMPANIES                    AN EQUAL OPPORTUNITY EMPLOYER

  DATE OF THIS APPLICATION  


 NAME:
First
Middle
Last
Phone No.
Date Available For Work
Type of Work Desired
ADDRESS (Include Street, City, State & Zip Code)
Applying for work:


Are you willing to transfer to another geographical location?  
(If yes, indicate any limitations)
E-Mail:
If you are less than 18 years of age, can you furnish a work permit if applicable? 

EMPLOYMENT HISTORY
Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer and account for all periods.
DATES
(MO. & YEAR)
NAMES AND LOCATION
(CITY, STATE) OF FIRM
JOB
TITLE
REASON FOR
LEAVING
YOUR
SALARY
1. PRESENT OR MOST RECENT EMPLOYMENT Starting:

Final:
Starting:

Final:
Start: 
Thru: 
Phone #   Your Supervisor: 
Work Performed:
2. EMPLOYMENT IMMEDIATELY PRIOR TO NO. 1 Starting:

Final:
Starting:

Final:
Start: 
Thru: 
Phone #   Your Supervisor: 
Work Performed:
3. EMPLOYMENT IMMEDIATELY PRIOR TO NO. 2 Starting:

Final:
Starting:

Final:
Start: 
Thru: 
Phone #   Your Supervisor: 
Work Performed:
4. EMPLOYMENT IMMEDIATELY PRIOR TO NO. 3 Starting:

Final:
Starting:

Final:
Start: 
Thru: 
Phone #   Your Supervisor: 
Work Performed:

Explain any gaps in employment dates
If discharged from any employer listed above, list name of employer and accurately describe the circumstances:
May we contact your current employer?  

EDUCATION AND TRAINING
If you need additional space, please continue on a separate sheet of paper.
  NAME OF SCHOOL LOCATION MAJOR SUBJECT NO. OF ACADEMIC
YEARS COMPLETED
HIGH SCHOOL  
GRADUATE?
 
YRS
COLLEGE
DEGREE?
 
YRS
COLLEGE
DEGREE?
 
YRS
VOCATIONAL
OR TRADE
CERTIFIGATE OR DEGREE?
 
YRS


SKILLS AND QUALIFICATIONS
What is your personal computer experience?
     
   
   
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.


PERSONAL REFERENCES
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name
Address/Phone #
Occupation
Name
Address/Phone #
Occupation
Name
Address/Phone #
Occupation


EVIDENCE OF ELIGIBILITY FOR WORK
Are you legally authorized to work in the United States?      If your answer is yes, and you are offered employment with Bituminous Insurance Companies, you will be required to show sufficient documentation as required by the Immigration Reform and Control Act of 1986.

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?      If yes, please indicate employee's name and your relationship to them.
Employee's Name: Relationship:

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.