Carrier Insurance Agency
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(814) 226-6580

Toll-free: (800) 822-9486

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Application for Employment

Applicant Instructions
Incomplete applications will not be processed. This application will be considered active for 180 days. Any applicant wishing to be considered beyond this time period should submit another application.
 
This application is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all questions completely and accurately. False or misleading statements on this form are grounds for terminating the application process, or, if discovered after employment, terminating employment. Additional testing of job-related skills or for the presence of illegal drugs in your body may be required prior to employment.
 
Applicant Information
First Name:*   Last Name:*  
Address:*
City:*   State:*  
Zip Code:*  
Email:*  
Cell Phone:   Home Phone:*  
 
Position Information
Which Position are you Interested in?*
Desired Salary:*  
Willing to Relocate:*  
Full or Part-time employment?*
Full-time Part-time
How many hours per week are you available?*  
Are you 18 years or older?*
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Are you prevented from being lawfully employed in the country due to Visa or Immigration issues?*
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Have you ever been bonded prior to employment?*
Yes No
Have you ever been convicted of a misdemeanor or felony?*
Yes No
 
Fields marked * are mandatory
Education Information
High School Name:*
City*   State*  
Received High School Diploma or GED?*
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College/University:*
City*   State*  
Years of College*   Major*  
Graduation Date/Expected Date:*  
 
Additional Schooling
 
Job Related Skills
Select all skills that apply:*
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Employment Experience
Please list three prior jobs, starting with your most recent employer first.
 
Employer 1
Employer:*
Address:*
City:*   State:*  
Zip Code:*   Phone:*  
Job Title:*   Supervisor:*  
Start Date:*   End Date:*  
Starting Salary/Wage:*   Ending Salary/Wage:*  
Reason for Leaving:*  
 
Employer 2
Employer:*
Address:*
City:*   State:*  
Zip Code:*   Phone:*  
Job Title:*   Supervisor:*  
Start Date:*   End Date:*  
Starting Salary/Wage:*   Ending Salary/Wage:*  
Reason for Leaving:*  
 
Employer 3
Employer:*
Address:*
City:*   State:*  
Zip Code:*   Phone:*  
Job Title:*   Supervisor:*  
Start Date:*   End Date:*  
Starting Salary/Wage:*   Ending Salary/Wage:*  
Reason for Leaving:*  
 
Fields marked * are mandatory
References
Please list the name, address, and phone number of the reference. Include the number of years known and the nature of the relationship.
 
Reference 1

Reference 2

Reference 3
 
How Did You Hear About Us?
 
I hereby certify that I have a genuine interest in being hired and that all of the foregoing statements are true and correct. I agree to assume a continuing responsibility to disclose additional or new information, called for by this Employment Application, but known to me only after this Application was completed, and understand that my failure to make such a disclosure, and that falsification of any of the information given herein, on any employment form or in any interview, are grounds for immediate termination, regardless of when such failure or falsification may be discovered.

I also understand that my employment may be terminated at any time, with or without cause, without liability to me for salary, wages, or other benefits except as may have been earned up to date of the termination of services.
 
 
Fields marked * are mandatory
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Location

Carrier Insurance Agency
21823 Rt. 68 Suite 3
Clarion, PA 16214
Phone: (814) 226-6580
Toll-Free: (800) 822-9486
Fax: (814) 226-8514

Email: carrierinsagencyinc@hotmail.com
Directions
(in front of Tractor Supply)

Office Hours

Monday - Friday: 8:00 AM - 5:00 PM

Companies We Represent

Erie Insurance
Progressive Insurance
Millvale Insurance