Job Application

Corporate Jobs Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.
Applicant Information
Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
What is the best time to contact you?*
E-mail*
Date available for work*

MonthDayYear
Applying for Position*
Applying for Position*
Desired Wage*
How did you hear about us?
Have you ever filed an application with Platinum Supplemental Insurance before?

YesNo
If yes, give approximate date
Have you ever been employed with Platinum Supplemental Insurance before?

YesNo
If yes, give date
Do any of your friends or relatives work here?

YesNo
If yes, state name and relationship
If you are under 18 years of age, can you provide proof of your eligibility to work?

YesNo
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.

YesNo
Education
AN EQUAL OPPORTUNITY EMPLOYER
High School*
Course of Study*
Years Completed*
Diploma*

YesNo
College
Course of Study
Years Completed
Diploma

YesNo
Graduate / Professional
Course of Study
Years Completed
Diploma

YesNo
Employment History
Start with your present or last position. Include any job-related military services or volunteer activities. Resumes may ony be used to supplement this application, not as a subsitute for completing it.
Company
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Work Performed
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for leaving
May we contact?

YesNo
Company
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Work Performed
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for leaving
May we contact?

YesNo
Company
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Work Performed
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for leaving
May we contact?

YesNo
Comments: Please explain any gaps in employment
Describe any job-related specialized training, interships, skills and extra-curricular activities
Other qualifications/special job-related skills acquired from employment or other experiences

Professional/Technical Licensing and/or Certifications

	Type of Cert./License	State	Cert./License Number	Expiration Date
*
*
*
*

CERTIFCATION STATEMENT

I certify that all information given on this application is true and complete to the best of my knowledge.

I understand that any false statements or omission of facts will be sufficient reason for termination of employment.

I further authorize Platinum Suppplemental Insurance Inc. to make all necessary and appropriate investigations to verifty the information contained in this application and release from all liability or responsibility all persons, companies, corporations or schools supplying information. Finally, I understand that any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause, and that this application is not an offer or contract of employment.
Please click the Submit button below after signing with Adobe eSign to complete the application process.
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Corporate Jobs Application

Applicant Information

Education

Employment History