Allstate Online Employment Form

*Date: (Ex 12/29/2010)

*First Name:

*Middle Name:

*Last Name:

*Street Address

Street Address (Cont)

*City

*State (Change if OK or other)

*Zip Code:

*Phone (Home) (Ex: 123-456-7895)

*Cell Phone:

*Email Address

*Best Time to Contact You:

Morning Afternoon Evening

*Date Available for Work:

*Driver\'s License Number:

*Driver\'s License State:

*Date of Birth: (Ex 12/29/1995)

*Type of Employement Desired:

Full-Time Part-Time Temporary Seasonal Ed CO-OP

*Are you legally eligible for employment in the US?

Yes No

*Do you have transportation to and from work?

Yes No

*Have you previously applied for employment with this company?

Yes No

If you have previously applied for work with this company, when did you apply?

*Have you ever been employed with this company before?

Yes No

If you have previously worked for this company, when did you work for us?

*Are you able to meet attendance requirements for the position?

Yes No

*Will you work overtime if required?

Yes No

If you cannot work overtime, please explain why?

*Have you ever been bonded?

Yes No

If you have been convicted, please explain. (Note: Convictions do not necessairly bar employment.)

*How did you find out about this job opening?

Website Advertisement Walk-In Employment Agency Other

Summarize any special training, skills, licenses, and/or certificates that may qualify you to perform job related functions in the position you are applying for.

List 3 Schools attended (if more than one) starting with most recent.

School	Years Completed	Degree/Diploma	GPA/Class Rank	Major	Minor (If Applies)

List Name, Telephone Number, and Years known for at least three known work, personal, or school references. The references cannot be related to you.

Name	Phone Number	Years Known

List last three employers starting with the last employer first.

Date: Month/Year	Employer	Salary	Position Held	Reason for Leaving
From: To:
From: To:
From: To:

Which of the above jobs did you like best?

What did you like most about the job you liked best?

Emergency Contact Information: Please list who you would like us to contact in the event of an emergency.

Name	Address	Phone Number

I certify all the information submitted by me on this application is true and complete. I understant that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to all company rules and regulations, and I agree that my employment and compensation can be terminated with or without cause and with or without notice at any time at either my or the company's option. I also understand that no company representative, other than it's president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time or make any agreement contrary to the foregoing.


Date	Full Name

Enter Code*:

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